Inspection on 08/11/05 for 191 Redditch Road

This inspection was carried out on 8th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

191 Redditch Road 01/05/07

191 Redditch Road 11/04/06

191 Redditch Road 28/04/05

191 Redditch Road 26/10/04

191 Redditch Road 19/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Redditch Road (191) Kings Norton Birmingham West Midlands B38 8RH Lead Inspector Kerry Coulter Unannounced Inspection 8th November 2005 12:50 Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 1 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 Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 2 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 Stationery 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) DS0000016959.V263909.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Redditch Road (191) Address Kings Norton Birmingham West Midlands B38 8RH 0121 680 2669 0121 680 2669 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bournville Village Trust Mrs Maxine Kallon Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Residents must be aged under 65 years That Mrs Kallon completes the Registered Managers Award by June 2005. That she undertakes a minimum of 21 hours dedicated management/administration time a week That Mrs Kallon attends training on the management of challenging behaviour on a course that is approved by CSCI by September 2005. 28/4/05 Date of last inspection 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) DS0000016959.V263909.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over five hours. Five clients and the staff on duty were spoken to. A partial tour of the premises took place. Care, staff and health and safety records were looked at. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from April 2005. Stephen Ellis (expert by experience) and his supporter from ‘Sandwell People First’ were there for part of the inspection. As a service user Stephen has an expert opinion on what it is like to receive services for people who have a learning disability. As part of the Inspection Team Stephen’s comments are included throughout this report. What the service does well: The home has a nice friendly atmosphere. The home is bright and cheerful. The staff were very friendly. Observations revealed positive relationships between staff and clients even though some individuals have severe communication difficulties. Clients have the opportunity to participate in appropriate activities, some based in the home with others in the community. Staff at the home seek input from other health and social care professionals 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. Clients bedrooms are well maintained and personalised. The staff were very happy to answer the questions from the Inspection Team. It is really good that one client has review meetings etc recorded on to tape so that he is fully included. The systems for client consultation are generally good. There was lots of evidence that clients are able to choose what food they would like. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 6 The home ensure all the required recruitment checks are completed before new members of staff start work in the home. The medication system is well managed. What has improved since the last inspection? What they could do better: Further work is required to some care plans to ensure clear guidelines are available for the night time checking of one client. Work is also needed on the way in which goals and actions are tracked. Health Action Plans should be implemented. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. The complaints procedure should be discussed at clients meetings to ensure that all clients are aware of it. The staff training files need updating, to accurately reflect the training staff have undertaken. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 7 Some policies and procedures require further improvement, policies must also be reviewed more regularly. Some areas of Health and Safety require attention to include fire training for some staff. 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) DS0000016959.V263909.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The Service User Guide provides prospective service users with relevant information about the home to enable them to make an informed choice about if they want to live there. Progress has been made to ensure the format is suitable for all of the current clients. EVIDENCE: As required at the last inspection the Manager has developed the service user guide to ensure it is available in formats suitable to the clients. Consideration should be given to the use of video or audio cassette. The home does not have any vacancies and clients have not recently been admitted to the home so actual practice was not assessed regarding admissions. However, the admissions procedure was sampled and was observed to be satisfactory. Assessments would be completed prior to a new client being admitted to the home, followed by an initial review after four weeks, with a final review three months after admission to ensure that the client had settled into the home. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 6,7,8 and 9 There is generally a clear and consistent care planning system in place to provide staff with information they need to meet service user needs with only minor improvements required. The systems for client consultation are generally good. Strategies for managing risks were generally clearly identified. EVIDENCE: The home has a service user plan for each individual, which includes detailed profiles, activity plans, and daily recording. Two plans were sampled. Both had been regularly reviewed. In addition, review meetings had been recently held in which the client had participated. Some goals and actions for the future had been agreed at the review meetings. The Manager will need to ensure that agreements are also documented regarding who will undertake the required action and the timescale for achieving it. This will contribute to the effective tracking and monitoring of any goals set. The review meeting for one client indicates that he is not happy with the arrangements for staff checking on him during the night. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 11 The Manager needs to review the care plan to ensure staff are directed clearly regarding the procedure for night checks. It is an area of good practice that one client has a care plan in a photograph and word format. Records sampled indicate that staff go through the care plan on a daily basis with this client to ensure she is aware of what activities are planned. The inspection team thought it good practice that for one client who has a visual impairment a copy of the care plan has been transferred to audio tape. Clients have a copy of their care plan in their bedroom. Two clients spoken with by the inspection team said they were not aware they had a copy and did not know what a care plan was. Perhaps the clients meetings could be used to discuss what a care plan is with the clients. Clients daily care records were of a good standard. Staff generally write detailed entries enabling the reader to track all the care provided. Records sampled and observation of practice indicates that choice is offered to include activities, meals, holidays, times of going to bed and getting up and décor of bedrooms. Clients 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. Risks had been identified, assessed and regularly reviewed. In addition the Manager has cross-referenced care plans to risk assessments so that the reader is naturally directed from one to the other. As required at the last inspection further work has been undertaken to manager the risks to one client and staff when crossing roads. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12, 13, 14, 15 and 17 Arrangements are in place so that people living in the home experience a meaningful lifestyle. Intergration within the community and pursuit of leisure activities are integral elements of the ethos of the home. Meals are both well managed, and provide client choice. 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. Some of the clients told the Inspection Team about the activities they participate in, this includes Ti-Chi, Church, Kennedy House disco and aromatherapy. One client said he would be starting college soon doing a music class. None of the clients go out on their own. Although there is a car that the home uses the clients are still supported to use public transport. If the clients stay at home during the day then they can help around the home doing tasks, such as putting their own clothes away or they go shopping. One client has a visual impairment so he has lots of things put on to tape. Every week the Royal Institute for the Blind send him the weekly news on tape so that he can keep up to date with what is happening. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 13 The client was listening to his tape while the Inspection Team was there. The Inspection Team asked him if he enjoyed listening to his tapes and he nodded. One client has a new laptop computer. She told the Inspection Team that she enjoys using it. One client has been on holiday to Disneyland Florida this year and two went to Chesterfield. Other clients have been on daytrips to Weston and Kew Gardens. Sampling of records and discussion with staff indicates that clients are supported to maintain contact with relatives and friends. Some clients have visits from family or spend time at the homes of relatives. One client does not have any close relatives but does have contact with a trustee. Friends have the opportunity to visit the home and have a meal. One client said that his friend comes to visit him. ‘Her mum drops her off for tea and then she picks her back up. We sometimes go to the pub, sometimes I go to her house.” One client told the Inspection Team that staff support her in marking the anniversary of her Father’s death by taking flowers to the crematorium. There was lots of evidence that clients are able to choose what food they would like. The clients’ get together on a Sunday to talk about what food they would like to put on the shopping list. One client informed the Inspection Team that she really enjoys going shopping and choosing the food. She knew what she was going to have for her tea and she said, “I chose Steak and Kidney pie, potatoes and vegetables.” The Inspection Team thought it was great that she knew what she was going to have for dinner, as some residents they speak to don’t know what food they are going to eat because the staff make those decisions. Food stocks in the kitchen were observed to be plentiful with supplies of fresh fruit and vegetables available. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19 and 20 The health needs of service users are generally met with evidence of good multi-disciplinary working taking place on a regular basis. Progress towards completing health action plans is not evident. 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: There is evidence of clients 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 client who has been diagnosed as in the early stages of dementia/Alzheimer’s disease. Sampled accident records for clients had been appropriately completed by staff and indicate a low level of occurrence of accidents. It was recommended previously that Health Action Plans should be implemented. 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. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 15 Staff spoken with were not aware of any progress being made towards the introduction of health action plans. The systems for the safe 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 storage of medication was not observed at this inspection, it was observed to be satisfactory at the last inspection. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 22 and 23 The complaints system in the home is generally satisfactory. The arrangements in place to protect clients from the possible risk of harm or abuse are not satisfactory and require improvement. EVIDENCE: Discussion with the Activities Co-ordinator indicates that the home has not received any complaints since the last inspection. Minutes of client meetings indicate that at each meeting clients are asked if there is something about the home they are not happy with. It is good practice that staff actively seek the comments of clients. Consideration could also be given to seeking comments or complaints from clients on an individual basis in private as there could be issues that they do not want to share with other clients. Some people here could work on designing their own poster about who and how they can complain and decide on where the posters should be. The complaints procedure should be discussed at clients meetings to ensure that all clients are aware of it. 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 three previous inspections. At each inspection staff have said that the Organisation are working on a policy but no actual progress is evident. At the last inspection it was identified that the adult protection policy needed some amendment as the policy instructs staff to leave the door ajar when assisting clients to bathe. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 17 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 subsequent response from Bourneville Village Trust indicated that the policy had been amended but the amended policy was not available at this inspection. Discussion with staff and subsequent discussion with the Manager indicates that one client has a history of saying things about staff that may not be true. In order to ensure that this client is protected the Manager needs to ensure that adequate guidelines are in place to guide staff as to when things need to be reported to the CSCI and Social Care and Health under adult protection. To this end it is strongly advised that the home works with Social Care and Health and/or the Community Nurse in the development of such guidelines. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The standard of the environment within this home is generally good providing clients with an attractive and homely place to live and meeting their needs. EVIDENCE: The home was seen to be generally well maintained, comfortable, and free from odour. Furniture, fixtures and fittings were of a good standard and well maintained. Since the last inspection new dining tables and chairs, coffee tables and cabinet have been purchased making the dining area a more pleasant place for clients. The hallway outside of the lounge had some areas of paintwork that required touching up but generally the Inspection Team found that the home was well maintained. All but one of the clients have recently had their bedrooms decorated, clients meetings indicate they had all been consulted regarding this. The clients have a key to their rooms so that they can lock their rooms if they want to. The Inspection Team thought that in one sampled bedroom the furniture was lovely and it was nicely decorated. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 19 The Inspection Team thought that consideration could be given to putting up some photographs of the clients up around the home so that it feels more like their own home. The access to the laundry is not possible for some clients as it is located on the first floor, and this has been documented within the statement of purpose. The laundry does not have a wash hand basin. At the last inspection it was recommended that consideration should be given to installing one. This would improve the arrangements for infection control. Staff spoken with were unaware if a basin was to be installed. 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. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 20 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 and 36 The staff team offer consistency of care and have a good understanding of client needs. Clients are protected by the home’s recruitment practices. Arrangements for supporting and developing staff are adequate but arrangements for monitoring and evaluating staff training could be improved. EVIDENCE: Support to clients is given in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. 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. 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. A training matrix summarising the training of the staff team as a whole was not available, it is recommended that one is completed. Individual staff training records were sampled. These were observed to require updating to reflect that some staff had recently attended fire, physical intervention and food hygiene training. Discussion with staff and sampling of records show that staff have received training from the community nurse on meeting the needs of someone who has dementia. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 21 The recruitment records of one new member of staff were sampled. An application form, Criminal Records Bureau check, proof of identity and one reference were available. Staff were unable to locate the second reference but this was forwarded to the CSCI shortly after the inspection. 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. Staff meetings are held on a regular basis. It is recommended that the minutes of the meetings include matters arising from the previous meeting and progress on previous actions agreed. This will enable the Manager and staff to track that actions have been completed and identify any outstanding issues. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 22 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 and 42 Some work to ensure that service user views underpin service development is being undertaken but this could be further improved. The arrangements for promoting and protecting the health, safety and welfare of the tenants are generally adequate but some areas of risk have been overlooked. EVIDENCE: The home is currently being well managed by a registered manager. However the Manager was due to leave employment at the home a few days after the inspection. The Activities Co-Ordinator will be managing the home on a temporary basis until a permanent manager is recruited. There was 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. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 23 The Manager has implemented a development plan for the home since the last inspection. This could be further improved by including timescales, a system for tracking if the plan is being met and what are the key indicators of plans being met. As recorded earlier in this report the adult protection and physical intervention procedure require improvement. Additionally, some policy and procedures were observed to be quite old, one was dated 1988 with no evidence of regular review. Policy’s must be reviewed on a regular basis to ensure they comply with any change in legislation and current good practice. Fire records showed that staff test the fire alarm is weekly and the emergency lighting monthly to make sure they are working. Regular fire drills take place to make sure that all clients and staff are aware of the procedure to follow in case of fire. Some staff have attended recent fire training but not all staff were able to attend this. Further training needs to be arranged for these staff. A Corgi registered engineer checked the gas equipment and an electrician tested the electrical wiring installation, reports stated that these in a satisfactory condition. Hoists and tracking systems are regularly tested. Of the three staff on duty, two were observed to be wearing shoes that were of a type with no back or toe covering. Given that part of staff roles is to use hoists and tracking systems this type of footwear would not give sturdy support to staff during such tasks. This has the potential to put both staff and clients at risk from accidents. A valid certificate of employers liability insurance was available in the home. Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 24 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 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Redditch Road (191) Score X 2 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 2 X 2 X DS0000016959.V263909.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 12(1)(a) & 15 Requirement Timescale for action 30/12/05 2 YA19 12(1)(a) 3 YA23 12(1)13(4) Care planning- The Manager will need to ensure that agreements regarding goals and aspirations are documented regarding who will undertake the required action and the timescale for achieving it. Ways in which clients goals are to be met need to be transferred in to the care plan. Health Action Plans for service 30/02/06 users must be developed. 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 adult protection 30/12/05 procedures 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 DS0000016959.V263909.R01.S.doc Version 5.0 Redditch Road (191) Page 26 4 YA23 5 YA23 6 7 YA35 YA40 8 YA42 9 YA42 door must remain closed unless an assessment of risk identifies the need for the door to be left ajar. Outstanding requirement from 30/6/05. 12(1)(a) In order to ensure that the 15 & 13(6) protection of one specific client the Manager needs to ensure that adequate guidelines are in place to guide staff as to when things need to be reported to the CSCI and Social Care and Health under adult protection. To this end it is strongly advised that the home works with Social Care and Health and/or the Community Nurse in the development of such guidelines. 13(7) & (8) The home must have a written policy on physical intervention, which must be in line with codes of professional practice, recognised by relevant professionals. (Outstanding from inspection of January 2004) 18 (1) Staff training records must be kept up to date to reflect all the training undertaken. 12(1) & Policy’s must be reviewed on a 13(6) regular basis to ensure they comply with any change in legislation and current good practice. 13(6,7,8)18 Training is required for all staff (1) in: Fire training, six monthly. ( Outstanding from 30/5/05, but majority of staff received recent training) 13(4) The Manager must ensure that staff wear appropriate footwear when undertaking people moving tasks. 30/12/05 30/01/06 30/12/05 30/01/06 08/12/05 15/12/05 Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 27 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 YA22 Good Practice Recommendations Some people here could work on designing their own poster about who and how they can complain and decide on where the posters should be. The complaints procedure should be discussed at clients meetings to ensure that all clients are aware of it. Consideration could be given to putting up some photographs of the clients up around the home so that it feels more like their own home. The laundry does not have a wash hand basin, 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. A training matrix summarising the training of the staff team as a whole was not available, it is recommended that one is completed. Staff meetings are held on a regular basis. It is recommended that the minutes of the meetings include matters arising from the previous meeting and progress on previous actions agreed. 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) 2 3 4 5 6 YA24 YA29 YA33 YA35 YA36 7 YA39 Redditch Road (191) DS0000016959.V263909.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Birmingham 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) DS0000016959.V263909.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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