Inspection on 01/09/05 for Walsall Road, 804

This inspection was carried out on 1st September 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walsall Road, 804 23/08/07

Walsall Road, 804 15/11/06

Walsall Road, 804 14/02/06

Walsall Road, 804 21/01/05

Walsall Road, 804 29/09/04

Walsall Road, 804 08/03/04

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 Walsall Road, 804 Great Barr Birmingham West Midlands B42 1EU Lead Inspector Gerard Hammond Unannounced Inspection 01 & 30 September 2005 09:00 Walsall Road, 804 DS0000016937.V256361.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 Walsall Road, 804 DS0000016937.V256361.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. Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Walsall Road, 804 Address Great Barr Birmingham West Midlands B42 1EU 0121 358 0412 0121 358 0009 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) Milbury Care Services Limited Mrs Lisa Hannah Carey Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years. Date of last inspection 21 January 2005 Brief Description of the Service: 804 Walsall Rd is registered to provide accommodation, care and support for three people with learning disabilities. The property is a detached bungalow, located on the main Birmingham to Walsall road in the Great Barr area of Birmingham. The Scott Arms Shopping Centre is within walking distance, and the home is well situated for local amenities including public transport and local shops. The accommodation includes a through lounge and dining area, a domestic scale kitchen, and separate laundry. The bathroom offers assisted bathing facilities, and there is a separate toilet available also. One of the three bedrooms has en-suite facilities. There is also a small office. To the rear of the property is an attractive private garden, which is accessible for wheelchair users via a ramp. The home is comfortably furnished and well maintained. There is off-road parking for several vehicles on the drive at the front of the house. The Registered Manager also has responsibility for another small home situated about a hundred yards further along the road. Both houses are run by Milbury Care Services. Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two visits. On the first visit, the Inspector was assisted by Stephen Ellis, a member of “Experts by Experience” (an organisation of people with learning difficulties, whose own experiences of life give them a unique perspective and expertise) or XbyX for short. Throughout this report Stephen is identified as “the XbyX”. During the inspection visit Stephen was supported by a member of staff from People First (Sandwell). Thanks are due to the residents and staff at Walsall Road for their co-operation and for their welcome. Direct observation and sampling of records (including personal files, care plans and safety records) were undertaken for the purposes of compiling this report. The Inspector met all of the residents, but detailed discussion of their views regarding the service was limited, due to their learning disabilities and communication support needs. Unfortunately it was not possible to meet with the Registered Manager, but the Inspector met with the Deputy Manager and the Organisations Operations Manager, as well as members of support staff, over the two visits. A tour of the premises was also completed. What the service does well: Residents at 804 Walsall Road live in a pleasant environment that members of the care team do their best to keep homely and welcoming. Basic personal care is given to a very good standard and residents are assisted to attend regular health checks, and supported by appropriate specialist professional help, according to their needs. The staff team is well motivated and keen to do things in the best interests of the people in their care. Relationships between residents and staff are relaxed and friendly, and support is given flexibly with warmth and respect. People are encouraged to do as much for themselves as they are able, according to their individual strengths and capabilities. Contact with families, friends and loved ones is actively encouraged and supported in accordance with people’s wishes. The staff team meets regularly and members receive individual supervision as required. The organisation provides regular training opportunities. Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The work that has gone on already towards care plan development should be continued and extended. Efforts to introduce approaches that are more personcentred should be encouraged and developed further. Care plans should be more detailed, so that how support is given is completely clear. Goals with outcomes that can be measured should be set across all areas of identified support need. These should then be looked at when the plan is reviewed, to see what has worked and what might need to be changed. There should be clear links between risk assessments and the care plans to which they relate. Some thought should be given to how care information is managed and presented. Care plans need to be working documents that are current, up to date, and where necessary information is easily located. The removal of old material and good use of indices will help in this regard. The staff team need to be supported in order to develop their capacity and expertise to communicate non-verbally. Improving their skills in this area has the potential to enhance the quality of life of all of the people living in the house. Opportunities for residents to engage in a wider range of activities, on a more frequent and regular basis, need to be explored as a matter of some priority. This should include opportunities both at home and in the wider community. Activities should be directly linked to individuals’ agreed care plan goals. The communal areas of the house are now in need of redecoration, and this should be planned for and appropriate action taken as soon as possible. Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 7 Vacant posts should be filled, so as to lessen the current dependency on agency personnel, in the interests of maintaining continuity of care. 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. Walsall Road, 804 DS0000016937.V256361.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 Walsall Road, 804 DS0000016937.V256361.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): 1, 2, 4 The Statement of Purpose needs to be amended to reflect the age range of residents cared for in the Home. Residents’ needs and aspirations have been appropriately assessed. The admissions procedure provides ample opportunities for prospective residents to visit and try out the Home, prior to any decision about placement. EVIDENCE: There has been one admission to the Home since the last inspection. Sadly, one of the former residents passed away. The new resident is a gentleman well known to the service, as he lived in one of the Organisation’s other homes in the immediate vicinity prior to moving to 804. His care needs have changed so that he now requires ground floor accommodation. The Statement of Purpose requires a slight amendment to reflect the age range of people now cared for in the Home, and an application to vary the conditions of registration should also be made. Appropriate assessment information of his current support needs was available on his personal records. In addition, he was able to visit and stay regularly, before making a decision to move in. He indicated directly that he is very happy in his new home, and has settled well. Walsall Road, 804 DS0000016937.V256361.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, 9 Care plans need to be developed further to include residents’ personal goals and to provide more detail of how support is given. Residents are supported to make decisions, but this is restricted by individuals’ capabilities. Responsible risk-taking is encouraged so as to support residents to be as independent as they are able. EVIDENCE: One of the issues looked at specifically by the XbyX was residents’ knowledge of and involvement in their individual care plans. None of the residents are able to understand what care plans in their current form are for. There is evidence of efforts being made to introduce person-centred approaches into care planning in the Home, and this is to be commended, encouraged and developed further. Care planning remains in need of further development, but it should be acknowledged that clear efforts are being made to move this forward. It may be that the Organisation should give consideration to providing additional Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 11 support and training for staff, specifically in assessing need, performing risk assessments, writing care plans, setting goals and reviewing and evaluating plans. The “communication passports” begun for residents are a good idea, but need more work. Currently they contain lots of photographs, some information about likes and dislikes, but very little detail about how individuals actually communicate. All of the residents have communication support needs, and an essential component of their individual plans must be guidance about how they make their needs known, what their particular gestures and body language mean, and so on. Communication underpins all other activity. Understanding individuals’ communication and developing opportunities to communicate is one thing that has huge potential to enhance people’s quality of life. Care plans should be detailed and provide precise guidance about how a person should be supported, according to their needs and wishes. Information management is an issue: it is important that this is easy to track and to find. It is recommended that all plans are clearly numbered and indexed appropriately. Plans should include goals with outcomes that can be measured, across all areas of identified support need. Goals should be evaluated at review and developed or amended as appropriate. Whole care plan reviews should take place at least every six months, with written records showing who takes part and how decisions are made. Direct observations supported the view that residents are enabled to make choices, though this is limited according to individuals’ capabilities. There are concerns in this connection about one of the residents, who is profoundly disabled and has no verbal communication. This further reinforces the point about the necessity of developing appropriate communication guidelines. Risk assessments should be directly cross-referenced to the care plan(s) to which they relate. These were appropriately indexed, but some were duplicated, and it was not possible to see which were most recent. Also, hazards are not always correctly identified, and risk assessments are confused with care plans. The purpose of individual risk assessment should be to identify potential hazards, make judgements about the likelihood of occurrence, and then to produce control measures, which should be incorporated into the care plan. However, risk assessments on file did provide evidence that responsible risk taking is seen as an important component of encouraging residents’ independence. Walsall Road, 804 DS0000016937.V256361.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): 12, 13, 15, 16, 17 Residents are able to take part in appropriate activities and to access their local community, but opportunities to do so are very limited. Contact with families and friends is actively supported and facilitated. Staff respect residents’ rights and encourage them to do as much for themselves as they can. Residents have access to a diet that is varied, balanced and nutritious. EVIDENCE: One of the residents has recently begun attending structured activities at a centre run by one of the local colleges. The “new” resident has indicated that he does not wish to go to college any more, as he now considers that he has retired, and his wishes are respected. A third resident has no formally organised activities. On the day of the inspection this person, who has complex support needs, spent the morning on the settee in the lounge, covered with a blanket. The XbyX reported that she was not engaged during that time until she had her lunch. Staff advised that they were looking to purchase more Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 13 items for use as communication aids and for sensory stimulation, and to improve the environment in her room. The previous inspection report raised the concern that the Home had neither the resources nor the appropriately trained staff to communicate with this person, and this continues to be the case. A proposed application for funding in order to access a specialist service for people with sensory impairments should now be actively pursued as a matter of priority. Records for another resident indicated activities undertaken to include listening to music, chatting to staff, watching TV, looking at books, clearing the table, going out for a drive and relaxing on the sofa, across a period of one week. Recording of activities undertaken is very limited, and no indication of the purposes of activities is given. Direct observation indicated that people living in the house are encouraged to do as much for themselves as they can, and to participate in domestic tasks around the house, such as tidying up and laundry, so as to encourage their independence. Records also show that residents’ access facilities in the local community, such as restaurants, pubs and shops, but opportunities are extremely limited. Records show that residents are supported to keep in touch with family, friends and loved ones. People are able to receive visitors at home or to keep in touch according to their wishes, and staff are keen to support contact as best they can. Staff said that there is a set menu, rotated on a four-weekly basis. However, in a home this size it is always possible to provide something else, if residents want something different. One of the residents told the XbX about his favourite foods, and all these items were stocked. Food stocks were plentiful and varied, and included fresh produce. Mealtimes were seen to be flexible, relaxed and unhurried. Walsall Road, 804 DS0000016937.V256361.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 Residents receive personal care in accordance with their needs and known preferences. Enhancing communication opportunities might improve this further. The physical and emotional health needs of people living in the house are generally met, but some aspects require attention. General practice with regard to the handling and administration of medication affords the residents with appropriate protection. EVIDENCE: The general appearance of people living in this house bears testimony to them having received a good standard of personal care. Interaction between staff and residents was observed to be warm, friendly and appropriately respectful. One resident told the XbyX that he liked his keyworker. When he was asked if he liked all the staff he replied, “Yes, they look after me”. Staff indicated that one resident, whose care needs are very complex, would push someone away if she doesn’t want to engage. As indicated earlier in this report, it is recommended that advice and support be sought to develop communication opportunities for this person (including extension of the use of Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 15 objects of reference and other sensory stimuli) so as to improve the quality of her care and encourage more positive engagement. There is evidence on file of attempts to introduce Health Action Planning, and this should now be taken forward. One person requires monitoring in respect of epileptic seizures. Recording was variable: some entries report the recovery time, some do not. The recording of seizure type was not consistent either. The care plan should include clear guidance about monitoring, and what needs to be recorded. It was noted that guidelines on the file referred to a letter from the Consultant, but did not indicate where this was. It is essential that care plan information concerning healthcare support is both current and easy to follow. The protocol for another resident’s bowel care monitoring indicates that medical advice must be sought after a certain period of time, without indicating how long this is. Staff who were on duty were unsure about how long this should be. The care plan must be amended to give clear guidance in this matter. This resident also requires meal supplements to ensure that her weight is maintained. Records show that this has improved in recent months. Accident recording was seen, and it was noted that no report (as required under Regulation 37, Care Homes Regulations 2001) had been submitted to CSCI in respect of an accident involving one of the residents on 28 July 2005. It is recommended that the accident book have a prominent note attached as a reminder to complete Regulation 37 reports as appropriate. However, it should be acknowledged that the Manager generally submits such reports to CSCI as a matter of routine. The medication administration record was examined, and completed appropriately. All medication was securely stored as required. A tube of cream opened on 08 July 2005 was still in the cupboard, but was disposed of subsequently. Containers of creams and lotions should be labelled with the date of opening, and disposed of within 28 days. Walsall Road, 804 DS0000016937.V256361.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 It is difficult to assess fully whether or not residents feel that their views are listened to and acted upon, due to their learning disabilities. General practice affords residents with protection from abuse, neglect and selfharm. EVIDENCE: There is a complaints policy in place, but this has little relevance for the people living in the house. No complaints have been received in respect of this service. The XbyX asked one resident if anything made him sad and he replied, “Nothing, I’m happy”. However, the other two residents are largely dependent on staff being sensitive to their general demeanour or small changes in behaviour or “body language”, to tell if they are upset or concerned about anything. It is recommended that the Adult Protection Policy be cross-referenced to local multi-agency guidelines, as a matter of good practice. A schedule of staff training on the office wall indicated that five members of staff have completed a course in the Protection of Vulnerable Adults From Abuse, and the remaining two people are scheduled to do this training shortly. Walsall Road, 804 DS0000016937.V256361.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 Residents enjoy living in a house that is comfortable, safe and homely. The house is clean and tidy, and a good standard of hygiene maintained. EVIDENCE: 804 Walsall Road is an adapted domestic scale property, and is very homely in style. People’s bedrooms are individual, with personal effects and possessions in evidence throughout. One man was particularly pleased and proud of his collection of things to do with cats, of which he is very fond. As noted at the time of the last inspection, communal areas are now showing signs of wear and tear. The XbyX observed that “the decoration of the home needs improving, I feel it needs to be brighter”. He also noted that the dining chairs were hard, and was advised by staff that a request had been lodged for some new cushions. The house is kept generally clean and tidy, with a good standard of hygiene maintained throughout. Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 18 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, 35, 36 There are some concerns about the capacity of the care team to support one resident with complex needs, and this must be addressed. There is currently an over-dependency on agency staff to meet minimum staffing requirements, and additional staff hours are required to develop activity opportunities for residents. A current staff training and development plan is required to assess accurately the care team’s training requirements. Staff are appropriately supervised. EVIDENCE: As recorded earlier in this report, there are concerns about the capacity of the current care team to meet the high communication support needs of one of the residents. Appropriate support, advice and assistance, as well as specialist training, should be made available to all members of the staff team in order to address this. The Deputy Manager advised that two staff members have left their posts recently, and that other personnel have recently reduced their hours. The Manager is also away on sick leave at present. At the time of the inspection, there was a daily dependency on agency staff to ensure that minimum staffing Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 19 requirements are met. It is essential that every effort be made to recruit to vacant posts. Consideration must also be given to providing additional staff to support improvements in activity opportunities. In the absence of the Registered Manager, it was not possible to ascertain fully the current position with regard to staff training and development. A staff training and development assessment and plan is required. This should include details of all training undertaken by each member of staff, highlighting any gaps (including refreshers) and indicate when this training is to be delivered, and by whom. Staff supervision records were sampled and found to be up to the required standard. It was also noted that staff group meetings are also taking place at regular intervals, as appropriate. In spite of obvious difficulties, the members of staff seen during the course of the inspection present themselves as well motivated, and keen to do what is best for the people in their care. Walsall Road, 804 DS0000016937.V256361.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): 42 General practice promotes the health, safety and welfare of the residents, but one or two items require improvements to recording. EVIDENCE: Safety records were sample checked. The fire alarm and emergency lighting systems have been serviced, and repaired. Weekly tests of these systems have generally been carried out, but there were some gaps in recording. The firefighting equipment has been serviced. The fire risk assessment has been reviewed, but is due for review again shortly. Previous inspection reports have indicated problems with the regulation of water temperatures in the house. It is clear that attempts have been made to rectify this, but there continue to be occasions when water temperatures to residents’ wash hand basins is unacceptably low, and this must be dealt with. Portable appliance testing of electrical equipment has been carried out, but is due to be done again in the near future. The five-year hard wiring certificate is in date, as is the Landlord’s Gas Safety Certificate. Fridge and freezer temperatures have been checked as required, and core temperatures of cooked food. Walsall Road, 804 DS0000016937.V256361.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 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Walsall Road, 804 Score 2 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000016937.V256361.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 YA1 Regulation 4, 5 & 6 Timescale for action The Statement of Purpose and 30/11/05 Service User Guide should be amended to reflect the age range of people now cared for in the Home, and an application made to CSCI to vary the conditions of registration to comply with this. Care plans should be developed 31/12/05 as indicated in the main body of this report, to include more detail about how support is given, to set goals with measurable outcomes and evaluate them at review. (See requirement no. 4 below also) Develop risk assessments as 31/12/05 indicated in the main body of this report, and cross-reference to the care plan(s) to which they relate, and vice versa. Further develop the range, 30/11/05 quality and frequency of activity opportunities for residents, and seek help for staff to enable them to support residents with communication support needs better. (See no. 7 below also) Complete the protocol for 02/09/05 seeking medical advice for the DS0000016937.V256361.R01.S.doc Version 5.0 Page 23 Requirement 2. YA6 15 (1) 3. YA9 13 (4a-c) 4. YA13YA12 16 (2m-n) 5. YA19 12 (1-3) Walsall Road, 804 resident requiring monitoring of bowel care. Develop epilepsy care plan and give clear guidance about monitoring and recording of seizures. 37 Dispose of creams and lotions 28 days after date of opening. Ensure that reports required under Regulation 37 are completed and sent to CSCI in respect of accidents to residents. Make arrangements for the communal areas of the home to be redecorated. Recruit to fill vacant posts and allocate staff hours to improve the frequency and range of activities available to people living in the house. (See no. 4 above also) Forward the staff training and development assessment and plan to CSCI, providing information detailed in the main body of this report. Ensure that the fire alarm is tested weekly and a written record kept. Ensure that water temperatures are monitored and action taken to address any problems identified. 6. 7. YA24 YA33 23 (2d) 18 (1a) 31/12/05 30/11/05 8. YA35 18 (1c) 30/11/05 9. YA42 13 (4) 08/09/05 Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 Page 24 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. Refer to Standard YA9 YA6 Good Practice Recommendations Develop clear and detailed communication guidelines for all residents, seeking professional advice and help as required. Develop and extend person-centred approaches and Health Action Planning Cross-reference Adult Protection Policy to current local multi-agency guidelines. 2. YA23 Walsall Road, 804 DS0000016937.V256361.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. Extracts may not be used or reproduced without the express permission of CSCI Walsall Road, 804 DS0000016937.V256361.R01.S.doc Version 5.0 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. 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