Inspection on 01/02/08 for St Albans Road (38)

This inspection was carried out on 1st February 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Albans Road (38) 10/08/07

St Albans Road (38) 27/06/06

St Albans Road (38) 14/12/05

St Albans Road (38) 11/08/05

St Albans Road (38) 10/03/05

St Albans Road (38) 18/05/04

St Albans Road (38) 14/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 St Albans Road (38) Moseley Birmingham West Midlands B13 9AR Lead Inspector Ashley Fawthrop Key Unannounced Inspection 1st February 2008 09:00 St Albans Road (38) DS0000016928.V359184.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 St Albans Road (38) DS0000016928.V359184.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. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Albans Road (38) Address Moseley Birmingham West Midlands B13 9AR 0121 449 3615 F/P 0121 449 3615 laura@trident-ha.org www.trident-ha.org.uk Trident Housing Association 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) vacant post Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Karen Clarke will attend a course on managing challenging behaviour of at least 3 days in duration. The course syllabus should be approved by the NCSC Karen Clarke should complete her NVQ level4 in Management of care by June 2004 10th August 2007 Date of last inspection Brief Description of the Service: St Albans is a purpose built detached, two storey building situated in a residential road in Moseley. The service accommodates six service users who have a learning disability, and a physical disability. Some service users have a behaviour that can challenge. The service is well situated for local amenities. There is a range of shops and Kings Heath shopping centre is close by as is Moseley village. The premises consist of six bedrooms with en-suite level access shower facilities. There is an open plan kitchen and dining room with good access for people with physical disabilities. Two communal areas are available one of which is utilised as a quiet room furnished with beanbags and easy chairs. There is a snoozelen room with a range of sensory equipment including fibre optic lights and lights. On the ground floor there is a communal bathroom that has a jacuzzi bath. The first floor is accessed via a passenger lift, with controls at a level people using a wheelchair can access. There is an office on the first floor and a sleep in facility is on the ground floor. This does not include separate staff bathing or toilet facilities. A separate laundry room is located at the rear of the premises. The rear garden has a patio area, which has recently been levelled and re-laid. The back garden is fenced and affords some degree of privacy. There is limited off road parking available. Information is made available using pictures and symbols to the people who use the service. CSCI reports are made available in the Home for anyone wishing to use the service. Weekly fees are £810 per week inclusive of a weekly contribution for toiletries and an annual payment towards the cost of holidays. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people using the service experience adequate quality outcomes. The visit took place on one day and this visit was unannounced. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Prior to the visit taking place a range of information was gathered including notifications received from the home and copies of the monthly visits to the service by the provider to look at how well the home is performing. This information has been used within this report Four people who live in the home were case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. All people who lived at the home were met. Due to their communication needs people who live at the home were not able to tell the inspector about what they thought about the service they receive. Some time on the inspection was spent observing staff interactions with residents. Discussions with two staff, service manager, operation manager and the acting Manager took place. What the service does well: People live in a home that has lots of space and aids available so that they live in a home that is suitable to meet their needs. Pictures and symbols are used a lot in the home to help people living there understand things easier. People living at the home are able to move around the home freely without restrictions so they can spend time on their own or with others. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 6 Lots of checks are done before some one comes to work at the home so that only people suitable to work with vulnerable people are employed. Staff at the home help people to look after their money safely so that they do not loose it or have it stolen. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People wishing to use the service have sufficient accessible information to enable them make an informed decision about whether they wanted to live at the home before they move in. EVIDENCE: The home has a statement of purpose that is specific to the home and the people who live there. The Statement of Purpose and a Service User Guide provide information about the home and the facilities available. Both of these documents include pictures and symbols to help make the information easier to understand. These were on display in the home so people living there could read them if they wanted to. There have been no admissions into the home since the last inspection. However, there is evidence that pre admissions assessments have been done St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 9 in the past that give staff enough information to start the care plan as soon as the person moves into the home. These show that people are given the opportunity to have extended visit to the home this allows staff to assess how they will meet people’s needs in the home. St Albans Road (38) DS0000016928.V359184.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): 6, 7 and 9 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning system and risk assessments are completed these do provide staff with all the information they need to meet peoples needs consistently and safely. However work needs to be done to make them completely people centred. EVIDENCE: Each person has an individual care plan. Four people were case tracked and their care plans were looked at in detail. Care plans are in the process of being developed and they contain sufficient detail so that staff can support people. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 11 Since the last inspection risk assessments have been updated and include the action staff should take to make sure that the risk at an acceptable level and what to do should an incident occur. Care plans provided some information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs but further detail was needed. The care plans are being developed to be more people centred and reflect the needs of the person they were written for and reflected their social and emotional needs as well as their physical care. This will help to make sure staff provide support in the way people prefer and need. It is pleasing that this has been recognised by the organisation who are starting to work on person centred plans for people. Staff are able to communicate with people using the service, and understand what their needs are by using picture boards or signing. Where a person has behaviours is challenging these behaviours are included in the care plan with guidelines available for staff to enable them to manage the behaviour safely, in a manner that respects the individual. Each person’s records included individual risk assessments. These had been thoroughly reviewed and updated and show how staff should support the person to reduce the risks from things such as aggression, road safety, seizures, hot drinks, accessing the community and choking. There is evidence that people who live in the home are supported to make some choices about their daily life. Staff were observed offering people choices about what they wanted to drink and whether or not to take apart in an activity or attend their day centre. There was evidence that people living at the home and the staff have a good and respectful relationship. Staff were seen to treat people with respect and maintain their privacy and dignity. Staff were able to describe people’s daily routine what they like to do on a daily basis and the action they take to meet these needs. This is good practice shows indicate that staff are aware of individuals preferred activities. It is good practice that one person has a communication book that he is supported to use to enable him to communicate with staff about his needs and choices. It was noted that this book needs to be updated to reflect the current staffing in the home. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 12 Due to people’s limited communication skills meetings do not occur, however one person attends the organisations tenants meetings regularly and the new manager has organised parents and carers meeting. Not all the care plans have been updated and there is more work to be done to bring them up to a good level including the comments from main cares, this could be done at the review. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16,17 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Leisure and recreational opportunities are good people experience a varied and interesting lifestyle inside the home and out in the community. EVIDENCE: People living at the home attend day centre opportunities Monday to Friday and in one instance where activities in the home had effected their well being and had effected their attendance at the day centre action has been taken by the home to reduce the persons stress levels and attendance has improved. This is good practice as it shows that staff see the importance of people having lives outside the home. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 14 Each person has an activity plan that is updated on a monthly basis this is in picture forma and shows what people have chosen to do. As well as showing social activities it also shows household tasks that people do such as tidying their rooms, doing their laundry and helping with meals. This is good practice as it gives people responsibility for their lives. There are records that show trips out and a full record is kept of how people are seen to enjoy activities or not. Many of the people who live at the home were out on the day of the inspection to day centres or on social activities with staff. People living in the home were clean and well presented in clothing appropriate to their age, the weather and gender. Records and discussions with staff show that people are supported to maintain relationships with their families on a regular basis with family birthday dates available so that residents can be supported to celebrate them. Families are welcome to visit at any time. Staff are undertaking training in equality and diversity, this will give them information about peoples sexual needs giving them the confidence to assess situations in the home and be able to make judgement on whether relationships are appropriate or not. This is good practice as it help people develop relationships inside and outside the home helps to protect them from abuse. There is a three-week rotational menu in place. Menus are written documents and people living in the home would not understand the information in them. The manger and staff are reviewing the menus to show the meals available in picture form as well as in writing. There is also evidence that people are involved in shopping and is part of the weekly activities in the home. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 15 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): 18, 19 and 20 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home can be confident that their health care needs are met in a way that promotes their health and welfare. However not all the health and personal needs of people have not been reviewed and updated. EVIDENCE: Health needs are monitored and appropriate action and intervention taken. The home is generally able to provide the aids and equipment recommended, but more attention could be given to the changing needs of people. Each person has Health Action Plan (HAP); this is an individual plan of what the person needs to do to stay healthy. These recorded that people are given the opportunity to attend doctors, dentist and chiropodist as required. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 16 People have a detailed record of how to support them with their personal care and any routines that may have. This information is useful in enabling staff to support people in the way they prefer including gender specific care for personal and intimate care task. Staff would benefit if these were expanded so that they also have information about the persons preferred routines for days where they do not go out to the day centre. Health needs are monitored and appropriate action and intervention taken. The home is generally able to provide the aids and equipment recommended, but more attention could be given to the changing needs of residents. One person’s file refers to the risk of choking does provide staff with information about high-risk foods that should be avoided to minimise the risk of choking. The home uses a monitored dosage medication system and stock control procedures are in place. There are storage facilities available so that medication is kept safely. Since the last inspection staff have received training in the safe administration medications. This is good practice as it gives staff the knowledge to administrated medications safely and reduces the risk of mistakes. There are no people in the home at present that self-administer medications, however, there are policies and procedures relating to the medication system including self-administration. On inspecting the medication system, the system was seen to be safe. The ordering storage, administration ands disposal of medications was done within professional good practice guidelines. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 17 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): 22 & 23 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff recognise and respond to the risk of abuse there are guidelines available to staff to make sure that people are safeguard from the risk of harm consistently. EVIDENCE: There have been no complaints since the last inspection. The home has a complaints procedure, which includes pictures and symbols to make the information easier to understand. People living in the home have limited communication skills and rely on staff to know their needs and know about things that make them unhappy or upset. There have been no complaints received by the home or CSCI since the last inspection. Care staff spoken to were aware of the action to take in the event of an allegation being made and would report it to a senior member of staff. People are protected by the homes procedures for managing their personal monies. A record of money held on behalf of residents is maintained; receipts St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 18 are available for all expenditure and two staff checks daily that money held is accurate. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 19 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): 24, 28, 29 & 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a clean well maintained home that meets their individual needs. EVIDENCE: The home was clean, tidy and generally well maintained. There has been some recent refurbishment and redecoration so that people live in a pleasant home. People have their own bedroom that includes an en-suite WC and shower facility. Some people choose to lock their bedroom doors if they want so that they can maintain their privacy. Many have decorated and furnished their own rooms giving them a feel of individuality and ownership. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 20 There are a number of rooms that have furniture provided by the home some of this furniture is worn and in need of repair, this furniture should be replaced. There is a choice of communal space available so that people can choose to spend time with others or on their own. Rooms reflect the taste and interest of people living there and there are a number of photographs around the home of them taking part in some activities. There is an assisted bathing facility available in the home so that people can choose to take a bath if they wish. The laundry is big enough so that people can take part in their own washing with staff support if they want. However, there are two washers and only one dryer. This is old and not very efficient the home should consider replacing this for a more up to date version. As reported in the last inspection it was noted that the laundry has a sluice sink but there are no hand wash facilities available for staff to wash their hands in this area. This creates the risk of cross infection and a hand basin should be fitted. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 21 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): 32, 34 & 35 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The training, development and supervision of staff have improved however more training is needed so they have the skills they need to meet the needs of the people they care for. EVIDENCE: Since the last inspection there has been a change of manager but the rest of the staff team has been stable. The manager is building relationships with both the staff and the people who live in the home by working on shifts so that she knows how the staff work and what they do on a day to day basis to meet the needs of the people. Staff working at the home also do the shopping, cleaning and cooking so they can be busy. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 22 Staff rotas show that the staff team have a good balance of both male and females so that people can choose to receive care from staff of the same or different gender. As recorded at the last inspection the culture of the staff team does not reflect the culture of the people living in the home. Consideration should be given to recruiting some more staff to reflect the culture of the residents. Files sampled and staff spoken to show that the home makes checks to make sure that prospective employees are suitable to work with vulnerable adults. Observations on the day show that some staff have positive relationships with the people living at the home and seemed to have a good understanding of peoples needs. There were records available in the home to show that staff have received training needed to meet peoples needs for example autism awareness, managing challenging behaviour, makaton, epilepsy, renal dysfunction, swallowing difficulties and performance management. Or had completed mandatory training in first aid, fire training, manual handling, and food hygiene, health and safety and adult protection. As recorded at the last inspection the home does not provide new staff with specialist training in meeting the needs of people with a learning disability (LDAF). The home has an induction-training programme to induct people into their role. However one member of staff felt that the induction programmes could be improved so they were more prepared to work at the home. The new manager has commenced supervision with staff so that she is aware of what skills need to be developed as well as supporting the staff. The manager has also commenced meetings with families of the people who live in the home, this is good practice as it gives people the opportunity to have a say in how the service develops. Regular staff meetings occur and these also demonstrate that staff do not always feel well supported or that residents are benefiting from a well motivated staff team. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 23 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): 37,39, 42 & 43 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a new manager since the last inspection, there is evidence that systems have improved, however, consistency will be needed so that people living in a home know that it is run in their best interest. EVIDENCE: The home has not had a registered manager for some time which means that resident and staff have experienced a lack of leadership and direction. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 24 However, there is a new manager that has worked at the home for six months and there is evidence that a lot of work has been put into the home to raise the standards of care. Although work has been undertaken there are still records that need updating and reorganising to show that the people benefit from living in a well run home. Most health and safety checks in the home are occurring at the required frequency so that the equipment, facilities and services are safe and well maintained. Weekly test of the fire system are made and have improved and the test of the emergency lighting system was up to date. The emergency procedures relating to fire have also been updated and staff are aware of the action they are supposed to take in the event of fire including the assembly point outside the building. Monthly visits take place by a representative of the organisation to comment on the quality of the service provided. Records of these were in the home but is disappointing that many of the issues identified by the inspection had not been noticed. The manger is developing a formal quality assurance system to encourage the development of the service. Those people who are able to contribute and their families are will be involved and the manager has started the process by having a meeting with the families of people who live in the home. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 2 St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA32 Regulation 18(2) Requirement There must be evidence that staff have received training so that they can meet the needs of the people living in the home including LDAF Timescale for action 01/08/08 2 YA19 15 Care plans must describe how to 01/08/08 meet residents health care needs so that staff have sufficient guidance to meet needs Care plans, risk assessments and 01/08/08 behaviour guidelines must be reviewed regularly to make sure that staff have up to date information Hand wash facilities must be 01/06/08 provided in the laundry to reduce the risk of cross infection 3 YA6 14(2) 4 YA30 16(2) j RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 27 No. 1 Refer to Standard YA18 Good Practice Recommendations Daily routines should be expanded to include the persons preferred activities for days they do not attend day centres. Evidence should be available in the home to demonstrate the training staff have done. Where measures are agreed in a persons supervision session then these should be followed so that they feel well supported A quality assurance system must be in place to encourage the development of the service. 2 3 YA35 YA36 4 YA39 St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI St Albans Road (38) DS0000016928.V359184.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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