Inspection on 13/12/05 for Sparrowfields

This inspection was carried out on 13th December 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 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sparrowfields 31/05/07

Sparrowfields 05/07/06

Sparrowfields 01/07/05

Sparrowfields 16/12/04

Sparrowfields 05/08/04

Sparrowfields 03/02/04

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 Sparrowfields 17-19 Alwold Road Weoley Castle Birmingham B29 5RR Lead Inspector Alison Ridge Unannounced Inspection 13th December 2005 08:00 Sparrowfields DS0000032644.V273317.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 Sparrowfields DS0000032644.V273317.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. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sparrowfields Address 17-19 Alwold Road Weoley Castle Birmingham B29 5RR 0121 428 2848 0121 428 2849 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) Shaw Healthcare (Specialist Services ) Ltd Ms Julie Quigley Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 6 Service Users with a learning disability aged 18- 65. 1st July 2005 Date of last inspection Brief Description of the Service: Sparrowfields was recently purpose built as a care home. The home accomodates six men, who all have a learning disability, and some additional needs regards challenging behaviour. The accomodation comprises of a kitchen, laundry room, main lounge with access to the garden, a quiet lounge, and a dining room on the ground floor. On the ground floor are two toilets, for staff and visitors use. On the first floor, are six single bedrooms, all with ensuite, a communal bathroom, and a room used by staff for medicines storage. The home has a small garden to the rear, which includes a shelter for smokers. At the front of the home is parking for several cars. The home is located in Weoley Castle, and is close to main transport links. Shopping and leisure facilities are available in Weoley Castle, Northfield and Birmingham would be accessable. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection team for this visit comprised of one CSCI inspector and Stephen Ellis who is an Expert by Experience (Exbyex). This visit started in the early morning and finished at lunchtime. The inspection team was pleased to meet all six of the men that live in the home, and to have opportunity to talk to them about their experiences of Sparrowfields. All the communal areas of the home were inspected, and some of the men showed the inspection team their personal rooms. Records about care, staffing, and health and safety were inspected. The registered manager of Sparrowfield’s had left at the end of the week prior to inspection. The deputy manager is currently acting up in this role. The inspection team extend their thanks to everyone who helped with this inspection. What the service does well: The inspectors spoke with four of the six men who live at Sparrowfields. With one exception, all the men reported favourably regarding all aspects of living in the home. Things the service users said the home does well are that they have their own rooms-decorated as they want them. They liked having ensuite bathrooms, and being able to use the bathroom when they wanted. How the people who live at Sparrowfields wish to live, and be supported is recorded in an Essential Life Plan. (ELP) These were detailed, and very individual to each person. People the inspection team asked about these did not recall being involved in the writing or review of the documents. The men who live at Sparrowfields get out of the home to undertake activities very regularly. The men, staff and records of care show activities are offered each day. These can include sports, courses, using local amenities, visiting family, and visiting places of interest. The inspection team found the home to be very well organised. The exbyex thought that things this home does well are that residents have lots of choice and control over their lives and residents are involved in the running of the home and are being encouraged to learn new skills and do things for themselves. He said he was made to feel very welcome during the visit, and that he felt very comfortable and relaxed in the home. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 6 He said he was offered lots of drinks and the staff offered lunch. What has improved since the last inspection? What they could do better: Inspection team did not find the environment at Sparrowfields to be well suited to the needs of the men accommodated. It was not clear that the space available had been well used. The garden area is not attractive, and has no seating. The home could be made more homely and personal to the people who live there. Ideas such as putting up photos or more pictures were raised during the visit. There are four full time staff vacancies for carers, and a new manager is required. Existing staff and some temporary staff are covering care vacancies. The home must recruit to these vacancies. The staff must evidence the work they undertake to make sure the right people move in to the home, and that people interested in living at Sparrowfields get the chance to come and try the home. One person reported they didn’t like the food. Staff must talk to him about the food he would like, and make sure this is available. The inspection team did not see any information around the home. This included fire procedures, or how to make a complaint. These should be available, and be in a format the men can access. The inspection team did not find that the men were aware of their plan of care, or if they had been asked about what to put in it. Staff must include the men in the writing and review of their plan, and make at least parts of it accessible to them. The men had not been on holiday this year. This is something they said they would like to do. Staff the inspection team spoke with said they are looking at this for next year. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 7 Medication management must get better to ensure people get all the right medicine at the right time. 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. Sparrowfields DS0000032644.V273317.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 Sparrowfields DS0000032644.V273317.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): 2, 4 It was not evident that prospective service users needs are assessed, or that opportunity to test-drive the home before moving in is provided. EVIDENCE: The inspector tracked the work undertaken with one service user who had recently moved in to the home. The information available at the time of inspection did not evidence that staff at Sparrowfields had undertaken an assessment of needs prior to the person moving in, or that the opportunity to undertake trial visits was provided. Sparrowfields DS0000032644.V273317.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, 9 All service users had a detailed, and individual plan of care. These did not show how service users wishes and preferences had been obtained, or included. Risks service users face and present were assessed, but not in adequate detail to ensure they are safely controlled and the risk effectively managed or reduced. EVIDENCE: The plans of two service users were assessed. The plan of a service user admitted to the home most recently was sampled. This was found to require significant development to underpin his known needs. The plan of a more established service user was assessed. This was developed to a much greater extent. The exbyex spoke to three of the service users about their individual plan of care, he commented,” All the residents had a care plan. They were not accessible plans and they were kept in the office. All three of the men that I spoke too were unable to tell me what a care plan was or what their plan contained. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 11 I think that the men that live there are more than able to be part of producing their plans. There are lots of creative ways that the men could contribute, using photographs or computer packages to make them easy to understand.” The service users the inspection team spoke with reported they are able to decision make. They gave examples of activities, food, decorating their room, and how to spend their money. The exbyex commented, “The residents chose how they wanted their rooms decorated. One man showed us his room and it was decorated in his favourite football teams colours. He had lots of things that had Aston Villa on them. He was so pleased to show me all of his Aston Villa things.” The record of consultation with service users was not frequent or consistent. It was not evident that the comments or ideas raised during the meetings had been actioned. The frequency of consultation must increase and ways of showing how the staff team have responded to service users must be provided. Risk assessments were available for all the service users to underpin risks they face or present. The inspector found these needed greater work to ensure they adequately reflect the risks being assessed. Examples of a risk assessment for community access that stated,” the service user is to be closely supervised.” And for family access, ”the service user is to be closely monitored” the document failed to inform staff of the level of supervision or monitoring that was required, and this could place the service user or others at risk of harm. Clinical risk was assessed for one person with epilepsy. The assessment in place failed to acknowledge risks such as going out alone, cooking or bathing. Risk assessments must be reviewed after critical incidents or near misses. Sparrowfields DS0000032644.V273317.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): 11, 12, 13, 14, 15, 17 Opportunities to undertake development and leisure activities are available, and as far as possible are tailor made to service users preferences and needs. Service users are supported to maintain contact with family and friends. Service users are offered a range of foods, which they are generally satisfied with. EVIDENCE: The opportunities available for one of the service users to access the community was assessed. This is an area in which the home supports the service users well. The daily diary showed he had been supported to undertake a wide range of interesting activities, this included at the weekends, and in some instances the evening. It was positive to read that the service user had been supported to undertake activities he liked including cooking. During the visit the service users were generally busy, and opportunities to undertake activities were provided. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 13 Service users went shopping, swimming, to college and undertook activities in the home. The exbyex commented, “The home seemed pretty busy when I arrived. One man was helping to wash the car. Throughout the day the men do chores around the home. They do their own laundry and help with the cooking and shopping. I think that it is really great that they are so involved in running the home and learning new skills.” Service users didn’t inform the exbyex that the opportunity to undertake activities in the evenings was plentiful. He commented, “None of the residents said that they go out on an evening.” He said, “I think that they could go out and do more things on an evening. There was a football table and dartboard for the men to use. This was good because those activities will encourage the men to interact with staff and each other. This is something the home should consult service users on, and develop the opportunities accordingly.” The daily records and discussion with the service users identified that they are supported to maintain active contact with their family and friends. One file sampled showed the support the service user needed regarding this had been planned. It was required this plan be further developed. The home has a four-week rolling menu. The choice of food over a four-week period is varied. The inspection team spoke with service users about food. The exbyex commented, “The residents go shopping with the staff. One man told me that the residents prepare the main meal on an evening with support. They all take it in turns. I think that this is great because the men are learning to cook for themselves. One man said that he likes the food and that he is asked what food he would like to have. He said, “We have a choice, good menu and good food.” Another man told me that he doesn’t go shopping with the staff very often but he likes the food. Another of the service users reported he cooks his own food, as he doesn’t like the food provided. The inspector followed this up with the acting manager. The staff must make sure they buy foods that the service users like, and which enables them to enjoy food of their culture.” Sparrowfields DS0000032644.V273317.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): 18, 19, 20 Service users are supported or encouraged to undertake personal care in a way and at a time suited to them. Healthcare monitoring is not consistently recorded, which could result in service users needs being unmet. Medication is not all given at the right dose at the right time and systems to underpin medication administration of, as required products are not robust. EVIDENCE: The inspection team met with all six of the men living at Sparrowfields. The man all looked well dressed. The morning routine was relaxed, and people got up as they chose during the morning. All the bedrooms have ensuite facilities and the room’s members of the inspection team visited were clean, and stocked with a personal supply of toiletries. Specific healthcare needs were tracked. The plan of one service user who has epilepsy was tracked. The plan did not adequately detail how this person was to be supported during a seizure. An immediate requirement that this be addressed was made. Some of the service users require support with anxiety or agitation. The plans to underpin this were identified as being too vague, and a requirement Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 15 regarding the development of these to make explicit the action staff must take was made. The plan of one recently admitted service user did not evidence that staff had used information provided by the previous placement to plan for known risks or care needs. Records of routine health appointments were available. These did not all evidence service users had been offered timely check ups. It was positive to see that new service users had been promptly registered with local health services. Behaviour plans were assessed for two men. These did not evidence in adequate detail the support service users need to manage their behaviour or anxiety. One service users assessment identified his mood needed to be monitored. There was no evidence that this was being undertaken, or that the staff were aware of the areas to be monitored. The plan of care set no baseline from which mood could be monitored. One plan of care developed at a previous placement was on file. The inspector noted this could put the service user and staff at risk if followed. This document must be reviewed and amended or archived as required. The review date on behaviour monitoring documents did not evidence these had been re-visited with the required frequency. One document was last dated June 2004. Such documents must be reviewed at least six monthly-sooner in the event of critical incident or a change of needs. The inspector could not evidence that medicines not blister packed were being given as prescribed. Audits undertaken at the inspection did not tally with records of receipt and administration. Some signature omissions by staff when administering medicines were noted. Creams that had been opened in excess of 28 days were in stock, and must be replaced. Staff must ensure they sign when applying creams. One dangerous practice with 5mg and 7.5mg Olanzapine was observed. This was brought to the attention of staff and required to cease. As required (PRN) medicine was available, that was not listed on the Medication Administration Record. No protocol in which to give this medicine was available. This must be developed. Sparrowfields DS0000032644.V273317.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, 23 The home has a robust complaints and adult protection procedure. This must be made available to service users in a format they can access. The service users feel able to raise concerns with staff in the home. EVIDENCE: There have been no complaints or Adult Protection concerns received regarding this service. The Adult Protection policy was assessed and was generally robust. The inspector noted that staff are not instructed to ensure the safety of the potential victim until page 8-section 5 of the report. It is required staff receive this information in stage 1. The inspection team talked to service users about their who they would talk to in event of a problem, and if they felt safe. The exbyex said he felt that the residents are safe in the home. He asked service users who they would speak to if they had any problems. They answered, “I would talk to the staff” None of the men knew who to complain too outside of the home. Inspectors noted that there were no easy to understand complaints or fire procedures displayed around the home. The exbyex said, “I think that it is essential that the residents knew these procedures in an easy to understand way. It is required these be developed, in a way service users can understand and access.” The minutes of some service users meetings identified concerns or matters the service users wanted resolving had been raised. There was no evidence of how this had been addressed. Staff must ensure they listen and act upon information raised by service users. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 17 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, 30 Sparrowfields is friendly and clean. Service users have their own space to develop as they wish. The premises are not well suited to the needs of the service users accommodated. EVIDENCE: Sparrowfield’s is a large domestic style property. The presentation of the home had improved since the last inspection. The lounge area was comfortable, and a new TV and entertainment system had been obtained recently. The kitchen had been redecorated, and a new cooker provided. Two service users had moved in to the home recently, and it was reported their rooms had been decorated. The number of locked doors had decreased which was also positive. Areas that urgently require work are the dining room, and the provision of a dishwasher in the kitchen. The inspection team found the home was clean and tidy. Several service users reported being involved in undertaking cleaning. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 18 The exbyex spoke with three service users who reported, “The residents chose how they want their rooms decorated. One room was decorated in the persons favourite football teams colours. He had lots of things that had Aston Villa on them and he was pleased to show me all of his Aston Villa things. He said that he was happy with his room. I think that it was good that he had his own shower room attached to his bedroom. He can have privacy and he doesn’t have to wait for the bathroom to be free before he can have a shower. One person I spoke with had a key to his room and he unlocked to show us around. Again I think that this is a good thing because he can make sure that no one goes into his room without his permission.“ The kitchen was generally clean and tidy. It has been recommended new crockery be obtained, as this was largely miss-matching and chipped. The staff must ensure kitchen cupboards are kept clean, and that foods are stored as the manufactures state, including in the fridge, or in airtight containers. Food that is bought fresh and frozen must be dated. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 19 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 Service users are supported by staff they know and like. There are enough staff to meet the needs of the service users accommodated. EVIDENCE: The inspection team received lots of positive comments about the staff that work in the home. The exbyex observed staff to be polite and friendly. Comments about the staff from service users included, “Not bad.” “I like them” and, “I like and care for them all.” One service user identified that there were not always enough staff on duty and he thought this should increase. One man raised concern regarding a specific member of staff. This was raised with the acting manager. The rota showed that four staff are provided per shift. At present there are 150 hours each week (approximately 4 full time) staff vacancies. Existing staff and some bank staff are covering this. At least half of these vacancies must be recruited to with permanent staff to ensure the service users are supported by people they know and who understand their needs. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 37, 42 The home has no registered manager, but interim measures are adequate to ensure service users needs continue to be met. Health and safety of service users, staff and visitors is generally well addressed. EVIDENCE: The home currently has no registered manager. The deputy manager is covering this post, and recruitment to this post has been scheduled. The inspector has requested Shaw Healthcare increase their monitoring visits and support to the home in this interim period. Health and safety records showed the fire alarm is not tested every week as is required. This must be undertaken. The fire risk assessment was completed in March 2005. This must be reviewed in light of the new service users admitted to the home, and the needs and risks they present. All other service and testing had been undertaken as is required. Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 21 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 X 1 X 1 X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X 2 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sparrowfields Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 1 X X X X 2 X DS0000032644.V273317.R01.S.doc Version 5.0 Page 22 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 YA2 Regulation 14(1)(a-b) Requirement All potential service users must be assessed by the home to ensure they can meet their needs. Potential service users must be offered a trial visit as part of pre-admission assessment. A record of this must be maintained. Unmet from the previous inspection. The review process for service users plans must clearly state the process followed to reach the decision. Evidence that service users have been involved in drafting and reviewing their plan of care must be available. Service users must have care plans to evidence how all their needs and wishes will be met. The home must increase consultation with service users and evidence this. Action taken in response to matters raised by service users must be provided. Risk assessments must fully under pin risks taken and posed DS0000032644.V273317.R01.S.doc Timescale for action 01/02/06 2 YA4 14(1)(a-b) 01/02/06 3 YA6 15(2)(b-c) 01/02/06 4 YA6 12(3) 01/02/06 5 6 YA6 YA22YA8 12(1)(a) 15 12(3) 16(2)(m-n) 01/02/06 01/02/06 7 YA9 13(4)(a-c) 01/02/06 Sparrowfields Version 5.0 Page 23 by service users. 8 YA14 16(2)(m-n) Service users must be offered greater opportunity to undertake activities of their choice in the evenings. Service users must be consulted about food they like, and this must be offered and provided. Service users with epilepsy must have a full care plan to underpin needs and risks in this area. Evidence that service users have been offered access to all routine and specific healthcare monitoring must be provided. Behaviour management plans must be developed to fully underpin needs in this area and be subject to periodic and as required review. Medication not blister packed must be audited to ensure it is given as prescribed. Creams must be used or discarded within 28days of opening. The use of As required medicines (PRN) must be underpinned with a protocol and medicines written on the MAR. A complaints policy in an accessible format for service users must be provided. Service users must be informed who to raise concerns with if they do not wish to do this with staff working at the home. The adult protection policy must make clear the need to ensure service users are safe at point one of the policy. Unmet from the previous inspection. The dining room must be DS0000032644.V273317.R01.S.doc 01/02/06 9 YA17 12(3) 16(2)(i) 12(1)(a) 01/02/06 10 YA19 09/01/06 11 YA19 12(1)(a) 13(2)(b) 12(1)(a) 13(2)(b) 16/01/06 12 YA19 16/01/06 13 14 15 YA20 YA20 YA20 13(2) 13(2) 13(2) 16/01/06 16/01/06 16/01/06 16 17 YA22 YA22 22 22 01/03/06 16/01/06 18 YA23 13(6) 16/01/06 19 YA24 23(2)(f-g) 01/02/06 Sparrowfields Version 5.0 Page 24 adequately furnished. 20 21 YA30 YA30 Kitchen cupboards must be cleaned inside and out and maintained in a clean condition. 13(3) Unmet from the previous inspection. Airtight storage must be provided for dry food products. Food products must be used or discarded on or before the use by date. 18(1)(a) All staff vacancies must be recruited to. 8(1)(a) The provider must recruit a competent manager skilled in the needs of service users accommodated. An application for registration must be made to the CSCI. 23(4)(c)(iv) Unmet from the previous inspection. Fire alarm tests must be undertaken weekly and a record of this maintained. 23(2)(d) 16/01/06 16/01/06 22 23 YA33 YA37 01/03/06 01/03/06 24 YA42 16/01/06 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 Refer to Standard YA30 YA30 Good Practice Recommendations It is recommended new crockery be obtained It is recommended a new dishwasher be obtained Sparrowfields DS0000032644.V273317.R01.S.doc Version 5.0 Page 25 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. 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