Inspection on 23/09/08 for Rushall Mews

This inspection was carried out on 23rd September 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Rushall Mews 09/02/10

Rushall Mews 22/09/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Rushall Mews New Street Rushall Walsall West Midlands WS4 1JQ Lead Inspector Amanda Hennessy Key Unannounced Inspection 23rd September 2008 10:00 X10015.doc Version 1.40 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 Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 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 Older People. 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. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rushall Mews Address New Street Rushall Walsall West Midlands WS4 1JQ 01922 720 300 01922 722 582 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) www.housing21.co.uk Housing 21 Care Home 27 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (27) of places Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 5 2. Old age not falling within any other category (OP) 27 The maximum number or service users to be accommodated is 27. This is the first inspection under the ownership of Housing 21. Date of last inspection Brief Description of the Service: Rushall Mews is a purpose built establishment providing intermediate care for up to twenty- seven older people. Intermediate care is short term care with an aim to improve peoples daily living skills and enable them whenever possible to return home. Care and support is usually provided for up to six weeks at a maximum. The home is separated into four units Chelsea, Linley, Homeward Bound and Avon (which is currently closed for refurbishment). Each unit has its own lounge come dining room,kitchenette and bathing facilities for dependent people. All bedrooms are single and have en-suite facilities. Homeward bound has twelve bungalows with people having their own bed sitting room and kitchen. The home is situated in Rushall close to local amenities and is on a main bus route. Limited car parking is available at the home. The home has pleasant and sheltered gardens. The service user guide seen identified that there is no charge for intermediate care for up to six weeks stay. Thereafter there will usually be a charge for respite care of £102.90 per week. The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 5 Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. The means the people who use this service experience adequate quality outcomes. This is the homes first inspection since its ownership changed in April 2008 although it has been a functioning care home for many years. This unannounced inspection was carried out over one day by one Inspector – Mrs Amanda Hennessy. The home had twenty-two people living there at the time of the inspection. Our time spent visiting the service was seven hours. As it was unannounced neither the service nor the provider knew we were going. Information for the report was gathered from a number of sources: a questionnaire- Annual Quality Assurance Assessment (AQAA) was completed by the homes manager and was sent to us; we looked at the premises, records and documents. We had discussions with staff and people who live at the home to gain their views on what it is like to live in and receive care at the home. We looked at how the service has responded to any concerns, how it protects people from abuse and how staff are recruited and trained. We also looked at the number of staff available to care for people at the home. Four people who were staying at the home were ‘case tracked’ this process involves establishing people’s experiences of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes of the care that they receive. Tracking peoples’ care helps us understand the experience of people who use the service. What the service does well: The home offers a specialised and valuable Intermediate Care service. People have a support plan to asssist them to maximise activities of daily living and assist them whenever possible to return home. People told us that they appreciated their stay and the assistance that they have had from staff at Rushall Mews: “Its nice here and they are very caring” and “without the carers I would not have been able to manage on my own”. Another person told us: Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 7 “I came here as I had gone off me feet and had fallen. They have taught me how to more safely use my frame, I am hoping to go home soon now”. Throughout the day a good rapport was observed between people staying at the home and staff, both the care staff and the healthcare professionals who work at Rushall Mews. All of the people spoken to were full of praise for the quality of the food provided at the home. People told us that the food is “good and I eat it all so I will have put weight on by the time I go home!”. The physical environment, its cleanliness and facilities are excellent and enable people to be independent. There are very good opportunities for staff training and people staying at the home benefit from an enthusiastic and well-trained staff group. The home has robust staff recruitment and selection, which minimises the risk of unsuitable people working at the home and protects people living there. What has improved since the last inspection? What they could do better: The home must agree the suitability of peoples’ needs coming to stay at Rushall Mews. Improved communication and agreement for admission will reduce the number of people who are unsuitable for intermediate care. Care records and plans of support need to reflect people’s individual needs choices and capabilities. Staff need to review and record peoples ongoing capabilities to demonstrate the effectiveness of their rehabilitation programme. The storage and administration of medicines at the home is undertaken safely and appropriately but further (minor) improvements could be made to reduce the risk of potential errors and keep people safer. Generally there are sufficient day time staff provided, although for services to continue to develop, staff numbers need to be reviewed. There is a need for additional staff on night duty as two staff is not sufficient to cover such a large building and the needs of people staying there. Please contact the provider for advice of actions taken in response to this Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and6. Quality in this outcome area is adequate. Required information about the home is available. People do have their needs assessed but assessments are not comprehensive to show that people will not benefit from intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides required information about the services they offer with an explanation of what “intermediate care” is. The statement of purpose and service user guide have recently been updated to reflect the changes to the homes ownership and give an accurate picture of what people can expect from the service. The service user guide is given to people when they come to stay at the home. The home has moved forward in the last twelve months to totally offer intermediate care. Intermediate care is offered to people who it is felt need Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 11 some assistance to improve their daily living skills and aid their independence that may have been lost following a deterioration in their health or a fall. People who are considered suitable for intermediate care whether they are in hospital or the community are informed of the service offered at Rushall Mews and are given a choice whether they wish to go there. If people express a wish to go to Rushall Mews they have an overview assessment of their needs which is sent to the home. When people are admitted they then receive a full assessment by a therapist. Staff said that they have received assessments of people who they have highlighted are unsuitable for intermediate care but their views have been disregarded. We were told despite staff concerns, further discussions were held with Senior Managers outside the home and, they were again told that they should have these people. We met some people and looked at their care records whom staff highlighted were unsuitable for rehabilitation. We found that despite the best efforts of all staff rehabilitation has been unsuccessful and agree with staff concerns. People usually have a stay of up to six weeks and have a plan of support to increase their daily living skills. The home has a multi- disciplinary team of Physiotherapists, Occupational Therapists, Community Nurses and Social Workers to support people in their aim to return home and assist their rehabilitation. There are weekly meeting when people have an opportunity to discuss their progress with all Professionals who are involved in their support. The home has one unit (referred to as Homeward bound) that has bungalows providing people with a bed sitting room with kitchenette and their own toilet. This excellent facility enables people to live more independently whilst also having the support of staff if they need it. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. People’s goals will more effectively be met if care plans reflect their individual needs and capabilities and there is more effective review of needs and capabilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home use Walsall’s ‘single assessment process’ for care planning to address people’s support needs. People have a support plan that details all professionals who are provide support such as Physiotherapists, Occupational Therapists, Doctors Community Nurses alongside the homes staff. Care plans seen provided basic information and were a check list of tasks to be undertaken such as; washing, dressing mobilising. Care plans did not identify people’s capabilities or summarise their achievements. We met one person who said that they are now able to walk further although were still a little unsteady. Care records for this person, as all records seen, did not identify their capabilities or improvements. Staff confirm what care is given by either initialling or ticking areas within the “support plan” without saying how much Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 13 assistance is needed. People do have a weekly meeting about their care. It would be beneficial if people’s capabilities and achievements are also recorded in their support plan so that everyone is aware what they can or can not do. People have access to a wide variety of healthcare professionals according to their needs. Medical care for the home is provided by Doctors at the local Health centre, although people still keep their own Doctor when they go home. Districts nurses, Physiotherapists, Occupational Therapists and Social workers are all based at the home and staff are able to refer to them when needed which was evident during the visit. We found one person who had developed a pressure sore, yet there was no pressure sore risk assessment which may have highlighted risk and required actions that could have been put in place to prevent skin damage. Other risk assessments were lacking for example, we did not see any for poor nutrition. The storage and administration of medicines at the home is undertaken by trained care staff and is done both safely and appropriately. There are weekly checks of all medicines to see if there are sufficient medicines available. There are risk assessments in place for people to administer their own medicines when they are able to. It is positive that people have a locked cupboard in their rooms where their medicines are stored. Risk assessments also detail when people need more assistance from staff such as opening medicines. When people need assistance arrangements are made for them to have their medicines in pre filled medicine boxes. We did advise staff that further (but minor) improvements could be made to reduce the risk of potential errors. For example some people are prescribed medicine “when required” but instructions should be available to tell staff when it should be given. Staff do sign to confirm that they give medicines but don’t always sign to confirm that creams and lotions are applied as they should. We also advised that two staff should confirm the accuracy of handwritten medication records to prevent error. The homes induction programme includes a section on treating people with respect. People told us that they are treated with respect. We observed staff to knock before entering bedrooms and toilets and interact in a friendly and open way using people’s choice of name. All rooms are single and have door locks to also give additional privacy should people want it. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. People have the opportunity to make choices about their life at the home and maintain relationships with friends and relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peoples’ interests and choices are recorded within their care records. People told us that they are able to get up and go to bed when they wanted and spend their day how and where they choose. “ I usually go to my room about 9.30 (night), but if there is something good on television we stay up and chat a bit longer.” Activities are organised on a daily basis by care staff with a plan for one morning and one afternoon activity on each unit. Care staff told us this can be difficult with the numbers of staff and more paperwork to complete. Activities include: games and quizzes. Visitors are able to visit the home at any reasonable time in the day. The Home has a four-week rolling menu. There are at least three meal choices available at each mealtime, although staff did say that if people do not like Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 15 either choice an alternate is offered. There is a dining kitchen for each unit where people living in that unit are able to have their meals if they want to. People using the service confirmed that they always have a choice offered and can have their meals in the dining room or if they prefer their own bedroom. People told us: “The food is very good – I can’t manage it all” and, “I can’t fault the food it much better than my meals on wheels”. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. People are listened to and can feel assured that the home will act in their best interests and protect them from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is included in the Service User Guide and is also displayed in the home. The home has had two complaints in the last year, one of which was upheld. There are appropriate record of complaints that have been received and investigations of the complaints that were undertaken. We have not received any complaints about the home since the change of ownership. People all told us that they know how to make a complaint: “I would tell the staff.” Staff we spoke to said that they would highlight any concerns to whoever is in charge of the shift or the manager. It is positive that all staff have all had adult protection training and had an awareness of what constitutes abuse. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. The home provides excellent accommodation which is clean and well maintained and has required facilities and aids to provide intermediate care and meet peoples needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is separated into four units: Linley, Chelsea, Avon and Homeward Bound (but will be renamed shortly as the home is now all intermediate care). Bedrooms in the home are single occupancy. Chelsea and Linley have been completed refurbished and provide pleasant and comfortable accommodation, bedrooms are generously proportioned and all have ensuite facilities. Avon is currently being refurbished and will provide accommodation to the same high standards. Homeward was historically the intermediate care unit and has twelve self contained bedsits in “bungalows and a further two bedsits within Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 18 the unit . All bedsits have a kitchen area and have their own toilet and have shared access to a bathroom. The bed sit units are equipped with varying domestic appliances to provide as near to home practice facilities and enable a more effective rehabilitation programme. The home has Physiotherapists and Occupational Therapists onsite with therapy rooms to aslso assist people to regain their independenceadded to this we have small quiet seated areas that the service users can utilise if they want to get away from there units. There are plesant sitting areas oustide where people staying at the home said they enjoy spening their time when the weather is good. The home is clean and tidy throughout- which staff are commended for particularly with the building work that is currently being undertaken. There are good arrangements to minimise the risk of cross infection with gloves, aprons, liquid soap and paper towels available throughout the home. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is adequate. Staff are trained and knowledgeable, but there may not always be sufficient staff to meet all peoples’ needs. Recruitment and selection processes protect people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We found that generally the home is staffed with appropriate numbers and skill mix to meet people’s needs. Staff told us that they feel that there is not always sufficient staff although staffing numbers have improved since the change of ownership and new staff have started working at the home. We do feel that two staff on night duty for the entire home is not sufficient to cover taking into account the size of the home and the dependency needs that people have who are staying there. People living at the home were very complementary about staff ”The staff are very good they always help me go to the toilet no matter how many times I need to ask them.” “They are very good but I think they are short staffed” Staff told us “Staffing is the main problem – but they say we are over staffed” and “When we raise concern about staffing levels we are told to blame those who are off sick.” Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 20 “ I’m worried what staffing will be like when the open Avon unit again and we have more people here.” There is a need for staffing levels for the home to be reviewed and ensure that it is sufficient to provide the support that people need. Staff we met spoke positively about support and training they receive and were knowledgeable about peoples’ needs. We observed good interaction between staff and people living at the home. The home has twenty-nine of its thirty-five care staff with a care qualification (minimum of National Vocational Qualification level 2), which is an excellent achievement. The manager has also told us that all those currently without a care qualification are registered to commence this award. In addition to their in-house training and care qualification all care staff attend the “COHORT” Training which is delivered by Health Care Professionals. The “Cohort” training, enables staff to work effectively with people who need to use the intermediate care service. The COHORT training is ongoing and the Manager has told us that all new staff will be able to access this training.This gives confidence that staff are knowledgeable and understand peoples’ care needs. Staff recruitment and selection is completed to the required standard. All staff files seen contained appropriate checks such as criminal records checks and references. The Manager also keeps a record of the interview. We were told that new staff have, induction training that meets the “Skills for Care” standards. Records of staff induction were available. It is positive that since the change in ownership all staff have had an updated induction to inform them of ‘Housing 21’ and its policies and procedures. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38. Quality in this outcome area is good. The home has effective leadership and appropriate health and safety practices that keep people safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager who has more than thirty years experience in managing a care home is adequately qualified. The manager is assisted by an experienced management team. In order to comply with legislation the manager needs to apply to us for registration The manager holds frequent staff meetings and maintains a record to ensure Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 22 that staff are kept updated and informed of changes and areas of development. The home use the Housing 21 quality assurance programme. It is positive that managers of the home do audits of practice based on the National Minimum Standards for older people. Managers are each given an area to review such as health and personal care, the environment and staffing assesses whether they are meeting the standards and when appropriate actions are needed which forms the development plan for the home. The homes Annual Quality Assurance assessment (AQAA) was sent to us when we asked and gave us a reasonable account of the services provided and identified areas for development. We were told that since there has been the change of ownership surveys are sent to all people who are discharged from the service, these surveys are sent directly to Housing 21 head office. The manager told us that a report is being made of the responses to the surveys and it will be available shortly. The financial records of the organisation were assessed at the time of the change of ownership and found to be appropriate. The home does not act as appointee for people using the service. There are appropriate arrangements in place when people request it to keep small amounts of money for services such as hairdressing and chiropody. There is a record of all transactions and receipts are available to confirm the transactions. It was also positive to be told that checks of the safe contents are undertaken at each shift change. Staff told us that they receive supervision but not always at the recommended frequency. Records of supervision we looked at showed us that it covers all aspects of practice. The home has an up to date health and safety policy for safe working practice with a range of risk assessments. Staff receive training and regular updates in all mandatory training. We were told that all staff have had training in Housing 21 policies and procedures since the change of the homes ownership. Maintenance contracts were randomly selected and were found to be up to date. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 3 3 4 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 12, 18. Requirement Staffing levels must be reviewed to ensure that there are sufficient staff available to meet people’s needs. To comply with legislation the manager must apply to us for registration. Timescale for action 30/11/08 2 OP31 Care Standards Act 2000 Section 11-1. 10/12/08 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 2 3 Refer to Standard OP7 OP7 OP9 Good Practice Recommendations Plans of support should reflect peoples individual choices, needs and capabilities. Care records should include a review of how people have achieved their goals and support plan. When medicines are prescribed “when required” instructions should be available to tell staff when it should be given. Two staff should sign to confirm the accuracy of DS0000071321.V371269.R01.S.doc Version 5.2 Page 25 4 OP9 Rushall Mews handwritten entries of medicines on the medication record. Rushall Mews DS0000071321.V371269.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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