Inspection on 25/07/06 for St Peters (Flat 1)

This inspection was carried out on 25th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

St Peters (Flat 1) 13/05/08

St Peters (Flat 1) 30/04/07

St Peters (Flat 1) 24/01/06

St Peters (Flat 1) 12/07/05

St Peters (Flat 1) 12/01/05

St Peters (Flat 1) 03/09/04

St Peters (Flat 1) 26/01/04

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 St Peters (Flat 1) College Road Saltley Birmingham West Midlands B8 3TF Lead Inspector Donna Ahern Unannounced Inspection 25th July 2006 08:50 St Peters (Flat 1) DS0000017140.V300283.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 Peters (Flat 1) DS0000017140.V300283.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 Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Peters (Flat 1) Address College Road Saltley Birmingham West Midlands B8 3TF 0121 328 4054 0121 328 2867 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.mencap.org.uk Royal Mencap Society Yvonne Thomas Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 24th January 2006 Brief Description of the Service: Flat 1 St Peters is registered for three adults who have learning disabilities. Mencap are the Registered Providers. The home is situated within a listed building that was once a religious seminary college to train priests. There is level access into the property. The home has three bedrooms and a lounge that is also used as a dining room. There is a kitchen, bathroom with W.C and an additional W.C. The home does not have a private garden area; there are communal grounds that are shared with other properties. There are two other flats that are registered homes within St Peters college flat 3 and 24. Each is registered as a separate home and there is two managers to oversee all three homes only one of the managers is registered (August 2005). CSCI have discussed with the providers the homes lack of fitness for purpose. As a result of these discussions the home have given a commitment to identify alternative premises more suited to the needs of residents. The organisation had made limited progress on its development plans for this service. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork was unannounced and took place over a morning and afternoon. Time was spent talking with residents and observing interactions between residents and staff. A partial inspection of the physical standards of the Flat 1 was undertaken. Residents care plans and risk assessments were inspected. Some Health and Safety records were inspected. The inspector had the opportunity to talk to one support worker. What the service does well: What has improved since the last inspection? What they could do better: Due to the concerns identified during the fieldwork an immediate requirement letter was sent to the provider and a meeting to discuss the home formally with CSCI has been arranged for 16th August 2006. Flat 1 St Peters does not meet the needs of the three residents. As reported in previous inspection reports there are plans in place to initially reduce occupancy levels and then to support residents to move on to a home that is appropriate for their assessed needs. The organisation had made no progress on its development plans. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 6 Further developments of residents care plans and risk assessments were required so that residents receive the support they require. The support that a resident was receiving at mealtime was not in line with the advice from other professionals and must be reviewed so that residents are not placed at risk. This matter was raised at the previous inspection in January 2006. Medication Record sheets (MAR) had not been signed when medication had been administered. The previous inspection report raised concern about gaps on the MAR sheets. Medication record sheets must be signed when medication is administered. Areas within the flat were looking very tired and worn. The bathroom has several cracked tiles. There were no disposable towels in the bathroom. The carpets throughout the flat were looking very dirty and worn. The home must be clean and comfortable for residents. The provider must review its procedures for the transfer of staff from a relief worker position to a permanent support worker position so that practice fully complies with employment legislation. The management arrangements for Flat 1 and its link with the other registered services of Flat 24 and 3 are confusing and not appropriate and must be formally reviewed. All the evidence available indicates a decline in the management of this service since January 2006. The management of health and safety was the main concern and must be addressed so that residents are not put at risk. 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. St Peters (Flat 1) DS0000017140.V300283.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 Peters (Flat 1) DS0000017140.V300283.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home was not fit for purpose; any proposed moves or changes for residents must be based on reassessments and evidence of a full consultation process with residents and their representatives. EVIDENCE: There have been no new admissions since the previous inspection. The residents have lived at the home for a number of years. Flat 1 had been deemed by CSCI at previous inspections as not fit for purpose. The organisation is in the process of seeking more suitable accommodation for residents. An interim plan was to utilize an adjacent flat for one resident and to reduce numbers in flat 1 from three to two, and improve bedroom sizes by making some alterations. There has been no progress on these development plans. The organisation must inform CSCI of it plans for this service. Any proposed moves or changes must be based on reassessments of resident’s needs and evidence of consultations with the residents and their representatives St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 9 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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Further development of residents care plans was required so that an up to date plan of care is in place so that resident’s needs, aspirations and goals are clearly documented and monitored. Further development of risk assessments was required so that the home can evidence that the risk residents face are well managed. EVIDENCE: There was evidence of ongoing work to residents care plans. The care plan structure was clear and had been produced in a format that was more resident focused and cross-referenced to risk assessments. The care plan must be further developed so that it includes details of resident’s goals, aspirations and activities. Staff must sign to say they have read and will follow residents care plans and risk assessments and will bring to the attention of the manager any concerns they may have. There was no evidence on the sampled care plans of formal reviews of residents needs with other relevant professionals. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 10 The review of individual care plans require some development so that there are details of who has been involved in the review and evidence of any decisions made in respect of the persons care plan. Some of the daily records sampled lacked detail and said “gone out” with no detail of where the person had gone. These must cross reference to residents individual care plans and include resident’s response to care and choices residents have made about their lives. A number of risk assessments were sampled. These required further development. When risk assessments are reviewed the manager had recorded “reviewed”. The review must include evidence that the risk factors in place have been considered in full. An example of this is a risk assessment in place for a resident who is at risk of falling out of bed. Safeguards and strategies are in place. The review of the risk assessment said, “Reviewed” with no mention of any incidents that may have occurred during the last six months or the appropriateness of the safeguards that had been implemented. A number of risk assessments were overdue a review “risk of weight loss” was due to be reviewed 10/10/2005 there was no evidence the review had taken place, and number of risk assessments reviewed in January 2006 were due to be reviewed again. The previous report required that the mealtime guidelines for the one resident who has dysphagia must be reviewed. There was concern because the person was supported to have their meal whist sitting in a comfy chair. The guidelines said that the person must be in “safe, upright posture when eating and sit on a dining room chair at a table”. An immediate requirement was made to review practice. At this inspection the person was again observed being supported to eat their meal sitting in the same position. There was no evidence that the practice or guidelines had been reviewed. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are supported to take part in community-based activities and go on holiday. The support residents receive at meal times must be reviewed. EVIDENCE: Residents were involved in household tasks making drinks, wiping and setting the tables and washing up. All three residents attend a day centre four days a week. The rota is planned so that residents get one to one staff support the day they don’t attend the day centre. Staff said they are then supported to go out shopping or places of interest. The inspection took place early morning and residents were having their breakfast. Two of the residents were involved in household tasks making drinks, wiping and clearing the tables and washing up. One of the residents was busy getting their bag ready for the day centre. Interactions between St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 12 residents and the staff member were positive. Support was given with sensitivity and respect. Resident seemed relaxed and freely accessed all areas of the home choosing to go to their own room the kitchen or sitting in the communal lounge. Two of the resident go to stay with their family each weekend, which leaves one resident at the home who receives one to one support. The men had been on holiday recently to Blackpool. Two staff had supported three residents. The holiday had not gone as well as previous holidays. It is important that the possible reasons for this are explored and documented and considered when future holidays are planned. A food and nutrition diary is kept for each resident. It indicated that residents receive a variety of food including salad and details of vegetables and indicated that a variety of tastes and cultural needs are provided for. The previous report required that the mealtime guidelines for a resident who has dysphagia must be reviewed. There was concern because the person was supported to have their meal whist sitting in a comfy chair. The guidelines said that the person must be in “safe, upright posture when eating and sit on a dining room chair at a table”. An immediate requirement was made to review practice. At this inspection the person was again observed being supported to eat their meal sitting in the same position. There was no evidence that the practice or guidelines had been reviewed. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents are supported to undertake a wide range of healthcare monitoring appointments; there must be evidence that the advice from other professionals has been acted upon. EVIDENCE: Residents are supported to access a range of health care professionals. Some development is required to risk assessments Residents personal appearance was good and indicated that residents receive good support to attend to their personal care needs. The home has a small stable staff team which gives continuity of care. There is a good ratio of male carers, which is positive for the residents who are all male so that residents can receive intimate care by a person of the same gender. One of the residents requires a tissue viability assessment. CSCI must be informed of the outcome. A risk assessment regarding weight loss had not been kept under review. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 14 The previous inspection on 24th January 2006 made an immediate requirement for the implementation of a risk assessment for the use of a resident’s wheelchair. It was required that this must be implemented by 10th February 2006. Examination of the risk assessment identified that this was not actioned until May 2006. It is of concern that it took four months to implement the risk assessment. Further information is required on the risk assessment it must specify in what circumstances the posture belt is used. Medication records were sampled. Medication Record sheets (MAR) had not been signed when medication had been administered on the morning for the previous day, for all three residents. The previous inspection report raised concern about gaps on the MAR sheets. Medication record sheets must be signed when medication is administered. Medication is stored in a locked wall mounted cupboard. Details of resident’s medication were included on their care plan. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The adult protection procedure must be developed so that the homes procedures protect residents from abuse. EVIDENCE: The Adult protection Policy required some amendments as raised at previous inspections. The policy must make it clear what the staff role is in the reporting of abuse (section C of the homes policy). The home had the No Secrets document and the Multi Agency Guidelines available on display in the staff room. Staff training on Adult protection is addressed through the organisations “Respond and Respect” training. There were no complaints logged on the record of complaints. The raising of complaints was discussed with the manager. She said staff are reminded to monitor residents closely and pick up on any changes in behaviour that may indicate their dissatisfaction or unhappiness with something. Residents are given an easy read complaints procedure with contact details of the organisation completed but would require staff support to take this further. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 16 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is not fit for purpose alternative provision must be provide so that residents live in a home that meets their assessed needs. EVIDENCE: Flat 1 had been deemed by CSCI at previous inspections as not fit for purpose. The organisation had informed CSCI that it was in the process of seeking more suitable accommodation for residents. In the interim the organisation had plans to upgrade the current provision, which would include utilising an unoccupied adjacent flat known as flat 2, reducing the numbers from three to two in flat one and improving bedroom facilities. No progress on development plans has been made since the previous inspection. The organisation must inform CSCI of its future plans for this service. The kitchen had been recently painted. All other areas of the flat were looking very tired and worn. The bathroom has several cracked tiles. There were no disposable towels in the bathroom. The carpets throughout the flat were looking very dirty and worn. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 17 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): 32,33,34,35,and 36 EVIDENCE: There was good interaction between residents and the support worker. The Staff member communicated well with residents and demonstrated that they knew their needs well. The staff rota was examined and this indicated that there was one or two staff on at core times of the day when the residents are at home. At weekends there is one staff member on duty across the working day as one of the residents goes home to their family. At night there continues to be one waking night staff member on duty. The manager said that there had been a recent appointment to the staff team, which should improve the staff situation and allow for some flexibility. The staffing of flat 1 had been dependent on a couple of regular support workers. Staff files seen indicated that supervision had slipped between January 2006 and June 2006. Application forms, two written references, evidence of CRB checks and identification; health declaration were on sampled files however there were no probation reviews. This shortfall had been identified and addressed by the registered manager. The provider must review its procedures for the transfer of staff from a relief worker position to a permanent support worker position so that practice fully complies with employment legislation. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 18 Staff training records indicated that some mandatory training required updating including Fire Safety and the safe administration of medication. The manager stated that this would be addressed through the organisations rolling training programme. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 19 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): 37,39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The management of health and safety matters that have a direct impact on residents is of concern and has the potential to pace residents at risk. EVIDENCE: The manager was successful in the Fit person interview process with CSCI in May 2006 and is the registered manager for flat 24, flat 3 and flat 1. Flat one also has a manager who is not registered who oversees the day-to-day management of the home. Some clarification is required about the management arrangements. The registered manager is responsible for Flat 1. However the service manager supervises the manager of flat 1 and not the registered manager. These arrangements are confusing and not appropriate and must be formally reviewed. All the evidence available indicates a decline in the management of this service since January 2006. The management of health and safety was the main concern. The registered manager was unable to clarify some of the queries St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 20 because she does not receive direct information about the home. A formal meeting has been arranged with the provider so that these concerns can be formally discussed. The provider has a quality assurance system. The service was due to have a full audit of its systems in the forthcoming months. This will be followed up on at the next inspection. The water temperature checks indicated that there had been a gap in recording between December 2005 and April 2006 a comment in the records said “there were no batteries in the thermometer”. Temperature recordings then show 52.2 for May 2006, 53.4 for June 2006 and 48.5 for July 2006. There was no evidence of what action had been taken to address the problem. The inspector was advised that the shower was not in use and action had been taken to resolve the problem in recent days. It is unacceptable that testing of the water temperatures had not been completed as required and then when reinstated there had been a delay in responding to the high temperatures. Staff had reported practice to the registered manager that when the shower got to hot the staff would then move the running shower away from the resident. The monthly safety checks identified a problem with the shower in March 2006 there was no evidence that any action had been taken by the manager. A safety consultant undertook a health and safety audit in December 2005 there is no evidence that the work identified has been actioned. The work place fire risk assessment dated 11/01/05 required review. St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 2 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 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 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 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 1 X 3 X X 1 X St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 22 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 2. Standard YA2 YA6 Regulation 14 (1) 15 (1) (2) Requirement The provider must inform CSCI of its future plans for this service. Resident’s care plans required further development. It must include details of resident’s goals, aspirations Daily records must be developed and include choices made and residents response to care. Risk assessments required further development. The outcome of a recent holiday be reviewed and considered when future holidays are planned. The mealtime arrangements for one resident required review. They must not conflict with the guidelines in place by Speech and Language Therapist. Outstanding requirement from 10/02/06. 6 YA19 12 (1) a, b One of the residents requires DS0000017140.V300283.R01.S.doc Timescale for action 30/09/06 30/09/06 3 YA7 15 (1) (2) 31/08/06 4. 5 YA9 YA14 13 (4) abc 12 (1) a and b 12 (1) a, b 31/08/06 30/09/06 5. YA17 04/08/06 31/08/06 Page 23 St Peters (Flat 1) Version 5.2 7 YA18 12 (1) (2) a tissue viability assessment. CSCI must be informed of the outcome. Support plans must be developed so that they reflect how the residents personal care needs will be met and how advice from other professionals has been implemented. Residents must receive appropriate support to monitor their weight. Staff must sign the Medication Administration Record when medication is administered. The Adult Protection Policy and Procedure required some development (Previous requirement September 2004). Broken tiles in the bathroom must be replaced. There must be effective systems in place for infection control. A maintenance and renewal programme is required for the fabric and decoration of the premises. The organisation must provide regular updates on progress of identifying suitable accommodation for residents The provider must review its procedures for the transfer of staff from a relief worker position to a permanent support worker position so that practice fully complies with employment legislation. 31/08/06 8 9 YA19 YA20 13 (4) 12 (1) a,b 17 (1) a Sch3 (i) 13 (6) 31/08/06 25/07/06 10 YA23 30/09/06 11 12 13 YA24 YA30 YA24 23 (2) d 16 (2) j 23 (2) b 31/08/06 26/07/06 30/09/06 14. YA24 23(1) a, b14(1) 31/08/06 15. YA34 7,9,19 Sch2 31/08/06 St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 24 16. YA35 18 (1) c Staff training must be arranged on Mandatory training. Staff must receive regular supervision with records kept. The management arrangement for this home must be reviewed formally with CSCI. The Workplace Fire Risk assessment required review. The health and safety checks implemented must be reviewed so that resident’s health and safety is promoted and protected. 30/09/06 17 18. YA36 YA37 18 (1) c 8 (1) (a) (b) (i) 30/09/06 31/08/06 19. 20. YA42 YA42 13 (4) 23 (4) 23 (4) c (v) 31/08/06 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI St Peters (Flat 1) DS0000017140.V300283.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!