Inspection on 08/11/06 for 296 - 298 Warren Farm Road

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

296 - 298 Warren Farm Road 02/06/06

296 - 298 Warren Farm Road 23/02/06

296 - 298 Warren Farm Road 12/10/05

296 - 298 Warren Farm Road 18/03/05

296 - 298 Warren Farm Road 09/11/04

296 - 298 Warren Farm Road 25/02/04

296 - 298 Warren Farm Road 21/11/03

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 Warren Farm Road, 296-298 Kingstanding Birmingham B44 0AD Lead Inspector Kath Strong Unannounced Inspection 8th November 2006 09:35 Warren Farm Road, 296-298 DS0000030417.V318586.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 Warren Farm Road, 296-298 DS0000030417.V318586.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. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warren Farm Road, 296-298 Address Kingstanding Birmingham B44 0AD 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) 0121 350 7076/7064 www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Rosalind Ray Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may provide care for five 18-65 year olds with a learning disability and sensory impairments In addition to care manager, a minimum of 4 suitably qualified and competent staff are on duty throughout the working day at all times, 7.30am - 10pm One suitably qualified and competent member of staff and a sleep-in member of staff throughout the night, 10pm - 7.30am 2nd June 2006 Date of last inspection Brief Description of the Service: 296 - 298 Warren Farm Road is registered to provide personal care and support to 5 adults with a learning disability, physical disability and sensory impairment, who have been assessed as requiring full assistance with daily living and other tasks. The home is staffed 24 hours a day including two waking night staff. Residents would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for residents. A number of adaptations have taken place within the home in order to meet the assessed needs of residents. The adaptations include hoists and tracking ceiling hoists, moving and handling aids, wide doorways and corridors to accommodate wheelchairs. The front door bell and the fire alarm are linked to a flashing light system for the benefit of those who are hard of hearing. Communal rooms consist of a lounge, kitchen/dining room, assisted bathroom and a secluded rear garden. Each bedroom includes en-suite facilities consisting of toilet, wash hand basin specialist bath or walk in shower. An en-suite sleep-in room is utilised by a member of staff every night. Residents are encouraged and supported to maintain links with their families and the local community. The care needs of residents are monitored and reviewed and action is taken to address any concerns. The home is situated in Kingstanding, a residential area of Birmingham and has good access to local amenities. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over a period of one day and assistance was provided by the registered manager. The home was fully occupied on the day of the visit. Information was gathered from speaking with staff and from interviews of staff. Time was spent with the residents but due to their needs they were not able to verbally express their views. Care, health and safety and the arrangements for medications were assessed. Staff personnel files were assessed and staff were observed whilst performing their duties and during a shift handover. A full tour of the premises was carried out. The home has been asked to complete a pre-inspection questionnaire, the fieldwork visit was carried out prior to the due date for receipt by CSCI. fieldwork analysis. At the conclusion verbal feedback was given to the registered manager. What the service does well: The organisation provides comfortable, warm, homely and safe accommodation that has been specially adapted to meet the needs of the people living there. Staff responded well to individual residents means of communicating, this involved various methods. Staff were committed to ensuring that residents were well cared for. Encouragement and assistance was given by staff to enable residents in accessing the amenities and activities within the home and the local community. Observations indicated that the manager operates an open door approach to all personnel. Adequate and consistent staffing levels are maintained over the 24 hour period to promote continuity of care for residents. The manager makes ongoing changes and introduces initiatives in the home and care plans to continually improve the services for the benefit of residents. Formal staff supervisory meetings are carried out monthly including an annual appraisal to ensure that staff are carrying their roles appropriately. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 6 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. Warren Farm Road, 296-298 DS0000030417.V318586.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 Warren Farm Road, 296-298 DS0000030417.V318586.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, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose provides prospective residents and relevant others with sufficient written details for them to make an informed decision about living at the home. The arrangements regarding pre-admission assessments indicate that adequate information is gathered to ensure that the individuals needs can be met by the home. Residents are supplied with contracts of terms and conditions that clearly advice them of their rights. EVIDENCE: The service user guide appears to include the statement of purpose and photographs of the home. A copy is located within each bedroom. Other items such as CSCI newsletters are also available. The written complaints procedure has also been produced in pictorial format to inform residents about the complaints process. The home has not had a new admission for an extensive period of time. The organisation has an admissions procedure and criteria for staff to follow. This includes a full assessment tool and the home would also obtain assessments from other agencies to gain a global picture of a persons needs before offering a placement. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 9 A copy of a contract of terms and conditions of residency was reviewed and appeared to contain all the required information to advice the resident of his rights whilst living at the home. Warren Farm Road, 296-298 DS0000030417.V318586.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide staff with adequate guidance on how to meet personal care needs and preferred individual routines of daily living. There is evidence of consultation to determine preferred lifestyles. EVIDENCE: All of the care plans were assessed. The home was in the process of reviewing the care plans with the purpose of ensuring all details are included, improving the layout of them and removing documentation that is no longer relevant. Those that have been reviewed were noted to be presented in an indexed and logical format. They include a comprehensive life history and background, likes and dislikes. Each file contains details regarding the most appropriate means of communications with symbols to assist this process. Information about daily routines and personal preferences have been gathered from various sources to assist staff in continuing these to ensure a quality lifestyle. Files contain detailed information about how staff should provide personal care, which includes mealtimes and eating. An activities and leisure programme is Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 11 also developed and these varied with each individual. The care plans appeared to provide good amounts of detailed information to assist staff in supporting each resident in maintaining a meaningful lifestyle. Risk assessments have been carried out in respect of many activities and procedures both in the home and externally. They were being reviewed regularly or when circumstances change. Consideration has been given to the range of issues that impact on resident’s rights due to their complex needs. The risk assessment tool needs to be further developed to include information regarding the degree of risk and the possible harm to others who may be involved with the task. This will ensure that all aspects are considered when developing the action plan to minimise the risks. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal development is encouraged and supported by staff. In the main activities are tailored to meet individual needs but staffing levels prohibit residents from accessing all of their preferred activities in the community. A wholesome and varied diet is offered and specialist dietary needs are catered for. EVIDENCE: Routines within the home are adapted to meet individual needs and preferences. There was evidence of one to one sessions with residents in providing physical and mental stimulus. Staff appeared to have developed an effective means of communication. Due to the complexity of needs staff have designed the most effective means of occupying and stimulating each resident. Relatives are consulted about activities to suit each person. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 13 There is comprehensive information about accessing the community. These include, visits to pubs, bowling, swimming, day trips, library and shopping. The home has two adapted vehicles for use solely for residents. It was noted that outings are not as frequent lately and that a resident who requires three carers to accompany her is unable to go swimming. Extra staff are needed to ensure that residents have a lifestyle that meets their personal preferences and fulfils their needs. There is evidence that residents and relevant other people are consulted about decision making, which may influence the day to day operating of the home. There is written information in respect of residents expressing their sexual needs. Families play an important role in acting as advocates and are involved in care planning and formal reviews. Staff work from a rolling menu for meals. Assessment of this indicated that the four meals each day offer choices. The home keeps a stock of frozen and tinned meals to accommodate requested alternatives. The home has a checklist to ensure that a minimum supply of foods are available at all times. One resident requires specific portion sizes and these were clearly documented. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Healthcare needs are met in practice but this is not always reflected in care plans. Staff practices in respect of administration of medications ensure that residents receive their medications safely. EVIDENCE: Residents have complex healthcare needs and this involves specific moving and handling regimes. The home was compiling written instructions on the use of each type of moving aids within the building. This is to ensure that individual needs are met and that staff carry out procedures correctly. The care plans included the various specialist needs of each resident and the care needed to promote health and well being. There was a wealth of information provided by external professionals and specific needs have been incorporated into the care plans. The manager was provided with feedback that some aspects of care/physical conditions had not been fully addressed: • A resident had swollen legs during the summer time and it was suggested this may have been as a result of the hot whether. The home needs to document the outcome of this condition Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 15 • • • • • • A resident who has a history of chest infections did not have a care plan to monitor the trends or to give staff guidance on what to observe for when a chest infection may be developing The sling sizes should be recorded when using as hoist Guidelines and entries must be signed and dated Crossings out must be signed and dated Risk assessments for healthcare need to include the severity of the risk and the possible harm to others who may be involved with a specific task Residents who have continence problems need to have clear staff instructions with timings recorded to give staff the knowledge to carry out their roles for the benefit of the residents. The above improvements are needed to provide a complete picture of needs and how they should be met. The arrangements for receiving, storage, administration, recording and disposal of medications were assessed and found to be satisfactory in ensuring that residents receive their medications as prescribed. A carer was observed whilst administering medications via a PEG tube and it was determined that the practice was carried out safely. All staff who administer medications have had accredited training. The deputy manager has undertaken an in depth course of training and regularly audits the medication processes. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident that their views will be listened to and complaints dealt with effectively. The arrangements regarding adult protection are robust and protect residents from the risk of abuse. EVIDENCE: The homes written complaints procedure is accompanied by symbols and is readily available in each resident’s bedroom. Neither the home or CSCI have received any formal complaints since the last inspection. The written policy regarding adult protection is comprehensive and is backed up by the Birmingham multi-agency guidelines. The home has demonstrated its ability to respond appropriately, this was in respect of an agency carer and CSCI were fully informed of this. Staff have received training in adult protection and how to deal with challenging behaviour. During an interview a carer demonstrated that she had sufficient knowledge to take action that is in the best interests of residents when abuse is suspected. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, comfortable, safe, hygienic and well maintained home. The communal rooms and garden offer a good range of choices for residents. EVIDENCE: The home was purpose built for its registered category and many adaptations have been incorporated. There is a range of specialist equipment to meet the current residents needs. The front door bell and fire alarm are linked to a flashing light system for the benefit of those who have hearing problems. The spacious lounge includes an integral loop system, television, video and hifi system. The kitchen diner is well equipped for staff to provide the required meals and is used by staff for handovers at the commencement of each shift. The secluded garden is well laid out for residents to spend time or have their meals during clement weather. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 18 Each of the bedrooms indicated that residents have chosen soft furnishings and colour regime when decorated. They were noted to be personalised to the degree preferred by the occupant. The rooms have en-suite facilities consisting of toilet, wash hand basin and assisted bath or assisted shower. There is also a communal bathroom and dedicated staff sleep-in room with ensuite facilities. The laundry room has a commercial washing machine and tumble dryer. All areas of the home were found to be hygienic and there was no evidence of malodour. The attention to detail achieved by staff presents a pleasing environment and the risk of infection is minimised. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels ensure that personal and care needs of residents are met but recreational preferences are sometimes prohibited because of staff shortages. Recruitment practices are robust and protect residents from risk of harm. Staff have received the mandatory training to meet residents needs but the induction programme needs to be checked to ensure that it is comprehensive. EVIDENCE: Due to the complex needs of residents a high ratio of staffing levels are required. Examination of the duty rota indicated that there are sufficient staff allocated to day and night duty to meet the personal and health needs of residents. The home has two bank staff that are asked to fill vacant shifts during holidays and sickness before an agency is approached, this ensures continuity of care. It was noted that residents are not offered outings as frequently as on previous occasions and a resident who requires three staff to accompany her to go swimming no longer attends. Lack of staffing for these occasions need to be reviewed and improved to ensure that residents lead their chosen lifestyles. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 20 Review of a sample of staff files indicated that the necessary checks are carried out before a post is offered to an applicant. This practice protects residents from risks of harm. Newly recruited staff undertake an induction that is provided by the organisation. The home needs to ensure that the programme reflects the contents of the Skills for Care package. The training matrix indicated that the organisation expects staff to undertake training in NVQ level 3. It was noted that less than 50 have achieved this. There was evidence that staff have carried out all mandatory training and numerous other courses that are relevant to the specialist needs of the current client group. This benefits residents and is viewed as being good practice. The organisation ensures that senior staff carry out monthly formal supervisory meetings with care staff that are fully documented. These arrangements serve to ensure that staff possess the knowledge and skills to carry out their roles effectively. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 21 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced and possesses the skills to oversee the day to day management of the home. The quality assurance system serves to promote continual improvements for the benefit of residents. Arrangements in respect of health and safety are robust and prevent residents from injuries. EVIDENCE: The manager is supported by a deputy manager who is supernumery for four days each week in order to carry out audits of standards of the services provided by the home. There was ample evidence that residents are treated individually and their needs developed and reviewed with the assistance of families, friends and professionals. An open and transparent approach was observed with staff readily accessing the manager to provide information or to seek guidance. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 22 Staff advised that the manager is approachable and supportive. Regular Regulation 26 visits are carried out and a written report of the findings given to the manager. A senior team within the organisation periodically assesses the home and the process includes obtaining opinions from stakeholders. A report is collated highlighting the good areas of practice, any shortfalls are included with timescales for resolving them. This indicates that the home is constantly striving in making improvements for the good of the residents. The manager also carries out in-house reviews every year and the deputy manager carries out other frequent audits. All relevant checks and servicing are carried out and the home has a range of risk assessments, which are regularly reviewed. The fire alarm system and emergency lighting systems are checked regularly and the findings recorded. Individual fire evacuation procedures are being developed, which takes into account the specific needs of each resident. All documentation pertaining to health and safety appeared to be in good order. The safety of residents appeared to be of paramount importance within the services supplied. Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 23 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 3 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 4 26 X 27 4 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 X 3 X X 3 x Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 24 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 YA9 Regulation 13(4)(a, b, c) Requirement Risk assessments on behalf of residents must be further developed to include the degree of risk and whom may be affected. Care plans must be further developed to include: • Short term health conditions and their outcomes • A specific programme for continence care must be developed • The sling size to be used for each resident who requires a hoist • All entries must include date and the authors signature • Crossings out must be dated and signed. The responsible individual must review and improve staffing levels to ensue that resident’s external recreational needs are met. The home must demonstrate DS0000030417.V318586.R01.S.doc Timescale for action 15/01/07 2. YA19 15(1) 31/01/07 3. YA32 18(1)a 31/01/07 4. YA35 1818(1)a 15/02/07 Page 25 Warren Farm Road, 296-298 Version 5.2 5. YA35 18(1)a that the induction programme for care staff includes all aspects of Skills for Care. At least 50 of all care staff must successfully complete training in NVQ level 2 or equivalent. The home must complete the already commenced work in developing a fire evacuation plan for each individual resident. 31/03/07 6. YA42 23(4)ciii 31/01/07 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 Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Warren Farm Road, 296-298 DS0000030417.V318586.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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