Inspection on 02/12/06 for 79 Slade Road

This inspection was carried out on 2nd December 2006.

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 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

79 Slade Road 22/01/09

79 Slade Road 24/01/08

79 Slade Road 15/02/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Slade Road, 79 Erdington Birmingham West Midlands B23 7PN Lead Inspector Sean Devine Key Unannounced Inspection 2 December 2006 08:30 nd Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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 Slade Road, 79 DS0000065020.V319104.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 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. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Slade Road, 79 Address Erdington Birmingham West Midlands B23 7PN 0121 326 7152 F/P 0121 326 7152 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.caretech-uk.com Caretech Community Service Limited Post vacant. Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: 79 Slade Road is a care home, registered to provide care and support to four people with a Learning Disability. At the present time the home accommodates four men, who also have some behaviours that challenge. The home is staffed 24 hours a day; overnight staff provision is a sleep in. The home has four single bedrooms. Three are on the first floor, and service users require full mobility to access this area of the home. There is also a bathroom and staff office/sleep in room on the first floor. On the ground floor is a communal lounge, dining room, kitchen, WC, and laundry area. The home has one ground floor bedroom, also fitted with an ensuite. The home is located in Erdington, Birmingham and is located close to local facilities and is conveniently sited for access to public transport. The care manager advised on pre inspection information that the fees at the home range from £1004.76 to £1610.30 each week. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over a period of one day by one regulation inspector. The four residents all returned a survey to the Commission known as “Have your say about…”, it was recorded that staff had assisted the residents to complete the survey. The home was also sent a pre inspection questionnaire, which had not been returned to the Commission and was collected at the time of inspection. The inspector was able to meet three of the four male residents, view two of their rooms and also look at the communal areas. Two of the residents were case tracked, which included for example meeting and having discussions with them, assessing how their medicines are managed and determining whether their varied needs are being effectively met. Records about health care of residents and health and safety were seen. The new care manager was not on duty and some records were inaccessible such as staff training and some staff recruitment records. It is suggested that this report be read alongside the report of the visit undertaken in February 2006. The Commission has received one complaint in 2006, which was passed onto the home to investigate. The inspector extends his thanks to everyone who assisted with this inspection. There were concerns at the inspection regarding staffing allocation and the financial records of one particular resident. The support staff could not answer some of the questions asked by the inspector. Following the inspection the new care manager provided additional information and revised staffing rotas. What the service does well: The residents all had important information in their own files, including an upto date contract, a residents guide, a statement of purpose and a complaints policy, some of this information also included pictures to help with understanding. The healthcare plans for the residents were well written, as if being said by the residents, they were focussed on their rights and choices and were all clearly and concisely written. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 6 Three of the four men indicated that they were happy and pleased with living at the home. When asked they said that they liked the staff and the food, and that they liked the other residents and their rooms. The home has a new care manager and the residents and staff on duty were positive about this and it is their opinion that it will get better at the home under this new manager. The men all had a single room, and those seen contained the items important to each of them. Senior managers from the organisation undertake a monthly visit write a report about this, which does indicate that they are aware of their responsibilities and take them seriously. One resident commented that he had all new bedroom furniture and was really pleased, whilst another advised that he too was having new bedroom furniture and a new bed. What has improved since the last inspection? What they could do better: As described above some of the requirements of the last inspection were met, however many were not and have been carried forward and these have been identified in the requirements section of this report. New concerns include the safe management of residents’ medicines and their money, staffing levels and the high use of agency staff. Other concerns that require improvement include ensuring that the changing health care needs of residents are reported to the GP, ensuring staff can effectively manage complaints, maintaining hygiene and cleanliness and improving fire safety. There are more requirements that the home needs to address and these are recorded within the requirements section of this report. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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 Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. These standards could not be fully assessed due to the home having a stable group of residents and no recent new admissions. However it is evident that residents do have available information about the home which will help them make a decision on whether it can meet their needs and expectations. EVIDENCE: There are four residents receiving a service and there have been no recent new admissions to the home as thus no residents have required a pre admission assessment and no residents have been to visit as part of the admission process. The senior staff on duty had some knowledge of what the admission process would include. Each resident’s file contained their copy of a residents guide, a statement of purpose, a complaints policy and their personal contract including a description of the accommodation, fees, services, policies (complaints) and facilities. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it can effectively plan to meet the needs and reduce the risks to residents. Some plans seen did not have the required resources and reviews of plans do not elicit whether the support has been effective. This may mean that residents are not provided with the care and the support they require. EVIDENCE: Two residents were case tracked. Residents have support plans, which had been written following a comprehensive assessment of the needs and strengths of each resident. Each care plan stated how each resident wanted staff to assist them and also stated how they want to be treated. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 11 For one resident managing diabetes and promoting a cultural diet indicated a risk. The resident was positive about maintaining his cultural identity and was made aware that areas of his diet may have a health implication. Health care plans were clear and concise guiding the resident and staff, for example they promoted both healthy food and cultural food and they advised on the frequency and need for primary care services. However the actions detailed in the support plan for another resident where additional staff are required could not be evidenced as it was not recorded on the staff rota and few records were available. Risk assessments were available for both residents, all these assessments did have a corresponding management plan and they were routinely reviewed. However some of the measures taken in risk management plans were not always adequate for example a risk assessment for epilepsy did not inform staff what they must do when the resident had a seizure and the reviews of these management plans did not say whether the management plan was effective or otherwise. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated it has the current ability to meet the varied individual lifestyle needs of the residents. It is not evident the home has the resources to ensure they are effectively and safely met, which may put residents at risk. EVIDENCE: Residents had an activity planner, which had been devised following consultation with the resident and also considering access to resources in the local community. Examples of how the residents choose to keep occupied and active include attending college, social clubs, shopping, cooking and domestic activities. One resident is very independent and often visits family and friends, travelling by local public transport. Other residents are more dependent and rely on staff support to access facilities such as college, Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 13 cinema, going out for walks and prompting with household and domestic chores. Records for some residents to confirm that they do follow their activity planner are poor, for example, one resident states I like to go out, don’t leave me here, take me with you (referring to staff); had been out the home on three occasions to college and four occasions for a walk in a one month period. The resident requires staff support to go to college and attendance in lessons, yet it was not recorded on staff rotas or in the daily records who goes with the resident. The food menu is planned with the residents, often using prompts such as pictures to help some of them choose their meals. The menu was seen to be varied, nutritional and regular to meet their individual needs, including their culture and health. The kitchen has been recently refurbished and was clean and tidy. However the colour coded chopping boards require replacing and food stocks appeared low. The inspector was advised that petty cash is available to purchase food and during the inspection a support worker needed to go to the shops (alone) to buy the main meal for that day and the following day. The inspector was advised that food shopping is a domestic activity, it included a regular shopping trip after planning the menu and also additional shopping where needed. A food safety risk assessment or recent report by an environmental health officer could not be found during the inspection however risk assessments for staff cooking with residents and use of cooking equipment was available. Since the inspection the manager has advised that a Hazard Analysis Critical Control Point assessment is available and was available at the time of inspection. The afternoon meal on the day of inspection was freshly prepared, and looked and smelt nice. The meal did not include any salad, vegetables or fruit. The kitchen has recently been refurbished and was modern and appeared easy to use. Following the inspection the manager forwarded staff training information to the Commission; this provided evidence that some staff have received basic food hygiene training whilst others have not. These staff have been nominated to undertake this training early in 2007. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated it has the capacity to ensure the healthcare needs of residents are effectively met. This may put the health and welfare of residents at risk. The personal care needs of residents are safely and individually met. EVIDENCE: The residents’ abilities to manage their own personal and healthcare varies greatly. One of the residents who was case tracked is independent in respect of personal care and partially with attending healthcare appointments. It was evident in care plans that little support was needed other than occasional prompts and encouragement. It was evident in records that the resident attends many appointments alone and when needed and has seen the GP, dentist and community nurse. However another resident is highly dependent on the staff to assist with certain areas of personal care and care plans and risk assessments are available to guide staff. Records indicate that staff have arranged appointments for this resident to see the GP, optician, nurse and phone calls have been made to NHS direct when needed. However for this Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 15 resident daily records completed by staff advised that an appointment with the GP was needed, however no records could be seen that record the resident did see the GP. Both residents have their medicines managed by the staff at the home. The system used is a monitored dosage system provided by a chemist. Each resident had a medication administration record; most medicines had been recorded when received at the home, however some had not. Stocks of the current cycle of routinely prescribed medicines were found to be correct, however the stock of Paracetamol for one resident, which is prescribed, “as required”, was inaccurate. Audits of stock of medicines were recorded up until 29/10/06. The Paracetamol had a written protocol to guide staff in its administration for the resident, this was found to be different to the directions recorded upon the medication administration record. The new cycle of medicines due to start had been stored safely, however the medicines had been received several days previously and the medication administration records had not been completed on the day the medicines had been received. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not demonstrating it has the ability to effectively protect residents from abuse and these failings may well increase the risk to residents. Residents and their representatives are able to raise complaints and have them effectively managed and where needed improvements made. EVIDENCE: Residents did not have any concerns or complaints. The surveys returned to the Commission completed by residents indicated that they were aware of how to make a complaint. The pre inspection questionnaire stated that two complaints had been received. The complaints records were not accessible for the inspector. The staff team were unclear how they would manage complaints when the manager was not on duty. They did not have access to any forms and would write it down for the manager’ ‘attention. However the complaints procedure has previously been assessed in other Care Tech homes and would ensure that complaints are quickly and effectively managed. The Commission has received one complaint in 2006, which was passed onto the home to investigate. The home has further developed residents risk assessments to include management plans of how they are protected from each other. The adult protection policy was not assessed and the requirement of the last inspection to ensure to ensure staff are instructed to make the resident safe, and to Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 17 contact social care and health with reference to local multi-agency guidance has been carried forward. The home does manage money on behalf of residents and provide a safekeeping service. There were some concerns at this inspection, firstly residents did not have risk assessments to state why they needed this facility and how if they needed it would it be safely managed, secondly records did not match with current balances, there was more money in an account that the records indicated, increasing the risk of possible abuse and finally cheques from a residents account where staff are signatories could not be reconciled. However since the inspection the manager has provided additional information about the cheques. The support worker in charge at the time of inspection advised that the agency staff who were at times in charge of the home would not handle residents money or go into the safe. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it has the ability to provide and maintain an environment that it safe, clean and fit for use by the residents. This will put residents health at risk and also have a negative impact on their self-esteem and emotional well-being. EVIDENCE: The survey forms completed by the residents indicated that the residents believe the home is kept clean and tidy. The communal areas were seen including the garden, lounge and dining area. The furniture in the dining area was new and so was the linoleum floor. Other communal areas were well decorated and furnished. One resident raised concerns that the television and the video recorder in the lounge are old and at times do not work properly. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 19 Two residents rooms were seen and one resident whilst showing the room was happy he had all he needed, one room was felt to be cold however this appeared to be his choice as other rooms were warm. Each room had been decorated in the style chosen by each resident, residents and staff advised that some beds and furniture had been replaced and some were due to be replaced. In one room the windows were dirty, net curtains were torn and the room required redecoration. The bathroom is upstairs and used by all residents, it is a domestic style bath and not appropriate for residents who cannot step safely into a bath. The toilet in the bathroom was heavily stained, on checking again some three hours later it was evident that it had not been cleaned. The décor in the bathroom requires improving as a matter of priority as walls and panels were heavily marked and the suite was very old and stained. Since the inspection the manager has advised that the bathroom has been refurbished. The laundry area was locked and detergents are kept inside. There is a tumble dryer and a washing machine, one resident requires some laundry to be sluiced; the machine does have a sluice cycle, and there is a wash hand basin. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not been able to demonstrate that the residents are supported by a regular team of staff, who have been safely recruited, available in good numbers and who are well trained. This may mean that the residents’ needs are not effectively met and their health and safety will put at risk. EVIDENCE: Examples of staff training records were received at the Commission after the visit. These indicated that the staff are undertaking safe working practice training such as manual handling, basic food hygiene and fire safety training and also training specific to the needs of resident such as epilepsy and diabetes awareness. The information sent also indicated that a training programme is in place for the year 2007. The pre inspection questionnaire recorded that two of the five permanent support workers had achieved the NVQ level 2 award or above. Staffing rotas and discussions with staff raised concern that there are shifts with only agency staff on duty. These concerns were raised post inspection Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 21 with the care manager who has revised the rotas to ensure there is always a permanent member of staff on duty. It was also a concern that some staff had received a phone call from agency staff whilst they were off duty to handle petty cash, however since the inspection the manager has advised that agency staff have been given guidance about residents personal allowances and petty cash procedures. It is a concern that the staffing levels are not always available to provide the needed support for residents to attend college. Some evidence of staff recruitment was forwarded to the Commission post inspection, mainly written references. The manager provided a letter with the recruitment information advising that if CSCI inspectors wish to assess and see the required documents being two employment references, application forms, health declarations and Criminal Records Bureau disclosures that these are kept at head office. The manager has also advised that the required recruitment information is safely maintained and is accessible when he is on duty. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not demonstrated that it is managed and conducted to provide a quality assessed and safe environment for the residents. This may mean that what is important to residents is not considered and that the health, safety and welfare of residents is put at risk. EVIDENCE: The care manager is new to the service; further information is required to assess the competency, experience and qualifications of the care manager, which will led by the Central Registration Team of the Commission. This could not be assessed at the time of the inspection. However it was apparent from talking to residents and staff and actions taken post inspection that the care manager is receptive and responsive to concerns. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 23 There is a quality assurance system, however since the change of manager it has not been kept upto date. There is no recent consultation with residents or any audits and a report is not available. The home has a fire system and equipment that is regularly tested and serviced. The fire risk assessment and evacuation plan were found to be incomplete, since the inspection the manager has forwarded the completed documents that were available at the time of inspection. Staff do attend fire drills yet records are infrequent. The care manager completes a monthly health and safety assessment and has recently identified improvements in the management of COSHH products and also the management of clinical waste. Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X X X 2 X X 2 X Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 17(1)(a) Sch 2 Requirement Unmet from the previous inspection 12/5/05. The service users contract must detail: - A copy of the Service Users plan - Arrangements for reviewing the needs and progress - Elements of the Care Management Plan provided outside the home Not fully assessed and is carried forward. Unmet from the previous inspection 12/5/05. Goal setting for service users must clearly show: who has set the goals, how they were agreed upon, who is responsible for meeting them, how it will be identified if they are met, when the goal was set, or who the goal is intended for? Partially completed, carried forward as a requirement of this inspection. Timescale for action 31/01/07 2 YA6 12(1)(2) 31/01/07 Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 26 3 YA9 15(a)(b)(c) 4 YA9 5 YA12 6 YA16 7 YA19 8 YA19 The registered person must ensure that the review of risk assessments include information about how effective the management plan has been or otherwise. 12(1) The registered person must 13(4) ensure that where risks are identified that a robust management plan is implemented, this must include guidance for staff when a resident has an epileptic seizure. 16(2)(m-n) Unmet from the previous inspection 12/5/05. A choice of leisure and learning opportunities in the community and in the home must be made available for service users to partake in on a daily basis. Activities must also be provided at weekends and evenings. Delivery of activities must be audited and shortfalls in staffing, transport or finance for example fed back to the head office to ensure service development in these areas. 12(2Unmet from the previous 3)(4a) inspection 12/5/05. The home must be run and staffed in such a way as not to impact on service users liberty to leave the building or undertake an activity of their choice. 12(1)(a) Unmet from the previous inspection 12/5/05. Evidence that incident recording has been analysed, and contributed to the review and development of care plans and staff practice must be available. 12(1) The registered person must 13(1)(b) ensure the GP is informed immediately of the changing health of residents. DS0000065020.V319104.R01.S.doc 31/01/07 31/12/06 31/01/07 31/01/07 31/01/07 31/12/06 Slade Road, 79 Version 5.2 Page 27 9 YA20 13(2) 10 YA20 13(2) 11 YA20 13(2) 12 YA22 22 13 YA23 13(6) The registered person must ensure that accurate stocks of residents’ medicines are maintained in the home at all times. The registered person must ensure that when medicines are received that staff sign the medication administration records to confirm receipt. The registered person must ensure that the PRN protocol includes the correct direction of use as prescribed by the doctor. The registered person must ensure that all staff are aware of the complaints procedure and can appropriately support a resident or their representative should they wish to make a complaint. Unmet from the previous inspection 12/5/05. The registered person must ensure that service users accommodated are protected from harm, and risk of harm. 31/12/06 31/12/06 31/12/06 31/01/07 31/12/06 14 YA23 15 YA24 16 YA26 This must include ensuring that risk assessments and records of how residents’ money is managed are upto date and fully completed, respectively. 13(6) The registered person must ensure that all residents have access to their money at any reasonable time. 23(2)(c) The registered person must ensure that equipment used at the homes is of good quality including providing a television and video recorder in communal areas that is fit for use. 23(2)(c)(d) The registered person must ensure that windows are kept clean and that curtains used are in good condition 31/12/06 31/01/07 31/12/06 Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 28 17 YA27 18 YA27 19 YA33 Unmet from the previous inspection 12/5/05. The bathroom must be upgraded. 16(2)(j)(k) The registered person must ensure all parts of the care home are kept clean; this must include high-risk areas such as toilets. 18(1)(a)(b) The registered person must ensure that at all times suitable qualified, competent and experienced persons are working in the home in such numbers as are appropriate to the health and welfare of service users. And Ensure that the employment of staff on a temporary basis will not prevent service users from receiving continuity of care as is reasonable to meet their needs. The registered person must ensure that an effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. The registered person must ensure that the concerns raised in the care managers monthly health and safety audit regarding COSHH products and clinical waste are fully and safely addressed. 23(2)(d) 31/01/07 20/12/06 20/12/06 20 YA39 24 31/01/07 21 YA42 13(4)(a)(c) 31/01/07 Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Slade Road, 79 DS0000065020.V319104.R01.S.doc Version 5.2 Page 31 - 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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