Inspection on 06/04/06 for 19 Wheelwright Road

This inspection was carried out on 6th April 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 36 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Wheelwright Road 30/01/08

19 Wheelwright Road 12/12/06

19 Wheelwright Road 04/10/05

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 Wheelwright Road, 19 Erdington Birmingham West Midlands B24 8PA Lead Inspector Alison Ridge Unannounced Inspection 6th April 2006 09:50 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wheelwright Road, 19 Address Erdington Birmingham West Midlands B24 8PA 0121 382 9746 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) Caretech Community Service Limited Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: 19 Wheelwright Road is a terraced house located in the Erdington area of Birmingham. The home is registered to provide care and support to three adults under the age of 65 who have a Learning disability. At present the home has two female, and one male service user. All service users have some difficult to manage behaviour, and autism. The home is staffed across the waking day with three staff, and at night a waking night staff and sleep in staff provide support. The home has three single bedrooms. None have ensuite, but all are fitted with a wash hand basin. The home has a bathroom with over bath shower, a communal lounge room, a music room, wc, dining room and kitchen. Laundry facilities are housed in an outhouse at the rear of the property. Service users accommodated at this home all require full mobility as no adapted facilities, or mobility aids are available. The home has a rear garden. The home has no off road parking. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook this inspection over one whole day. Information used in the report was collected by talking with the three people who live in the home, and observing the way they were enabled and supported throughout the visit. The inspector looked around the home, and premises. Records about care, food, staffing, and health and safety were all assessed. The home has a new manager, and the inspector was pleased to meet him, and talk with him about the home during the visit. The inspector extends her thanks to everyone who assisted with the inspection. What the service does well: What has improved since the last inspection? The hall, stairs and landing have been redecorated, and fitted with a new carpet since the last inspection. The appearance of these areas is much improved. One service users bedroom had also been developed, and now looks much more comfortable and homely. Caretech has recruited a manager for the home. This home has been without a permanent stable manager for four years. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 6 One of the people who lives in this home, has been supported to go out. This is a big improvement for the person, as previously their leisure opportunities were limited to the home. Some good work has been undertaken, to help people that don’t use words to communicate, let staff know how they feel, and what they would like. This work has included taking photos, and using signs and symbols. Caretech have recruited to most of the staff vacancies for this home. This means the people living in the home are supported by staff they have got to know, and who know them. 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. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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): X Standards not assessed at this inspection. EVIDENCE: This home has a stable group of service users. There are no residential vacancies, and there have been no new admissions since the last inspection. These standards were not assessed. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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, 8, 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments remain largely unchanged from the previous inspection. The documents do not fully reflect the service users needs, or provide staff with clear, accessible guidance on how to meet their needs. Care documents had not been reviewed when relevant incidents had occurred. Service users contribution to care and lifestyle planning had increased but remains in need of further development. EVIDENCE: The plans of two service users were assessed at this inspection. The plans were presented in an all word format, and were not accessible to the service users to whom they refer. The home had not undertaken person centred planning with the service users. The content of the plans sampled did not show that service users were consulted about the contents, or about how they wish their care needs to be met. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 10 One record of activities that was in a format accessible to the service user, was found stored in the staff office. It was recommended this be reviewed so the service user can fully benefit from access to the document. Staff had undertaken some new care planning work since the last inspection. This work contained some insightful information about the service users, which was very personalised to them. The plans often needed to be further developed to explain how the identified need was to be met. For example in one plan it stated, “I want staff to guide me at the dinner table to eat appropriately and not stuff too much food in my mouth”, the plan didn’t go on to inform staff on the way in which they were to provide this support, nor did the plan cross reference to a relevant risk assessment. The second set of talk time notes assessed were a record of questions asked to the service user such as, “Would you like to go bowling?” It was not evident that suitable communication aids had been utilised to assist the service user understand the question and make an informed decision. The inspector identified wishes and ideas raised in the talk time for which no evidence of them being offered or undertaken was available. During the inspection opportunities for the service users to participate in household activities were provided. This included helping with food preparation, laundry and vacuuming. Daily records completed by staff, often reflected the staff’s experience of the shift, rather than the service users. It is recommended this be explored with staff. The risk assessments for the service users were found to require review to fully reflect service users needs, and to ensure control measures are effective and in place. A risk assessment regards the safety of one service user, from physical and psychological attack by other service users was assessed. This had not been reviewed after incidents in which another service user had physically harmed the service user, or when it was identified in a care review for another service user, that they were expressing negative intentions towards this service user. Another service user tracked has previously experienced difficult to manage behaviour when in the community. It was of concern that events such as swimming, and travelling by public transport had been undertaken, without being risk assessed prior to the activity. The inspector considered this put the service user, staff and the public at potential risk of harm. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 11 The inspector observed one piece of staff practice in which two service users were left unsupervised on the ground floor of the home, with the front door open, while staff arranged money to pay a bill. This practice was directly in conflict with the risk assessment, and put these service users at risk from each other, and absconding through the open door. At lunchtime it was observed one service user ate only with plastic cutlery and crockery. The inspector was informed this was due to the assessed potential of crockery and cutlery being used as a weapon. This action did not well control this risk, as other service user, and staff ate with metal cutlery, and from crockery plates. These were within easy reach of the service user, should she have decided to take them. Neither this risk, nor restriction was assessed. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users have an increased number of opportunities to undertake leisure in the home and community, which increases their opportunity to undertake leisure, learning and wider participation. The way in which these are funded must be reviewed. Service users are supported to stay in touch with people important to them. The food provided is plentiful, and includes fresh products. The food needs to be reviewed to ensure it assists service users achieve and maintain a healthy weight. EVIDENCE: Two of the service users have the opportunity to access formal day opportunities at a local college. It was apparent that service users have developed new skills in the areas of house keeping, these are not formally planned or recorded, which dose not enable progress towards greater independence to be effectively monitored. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 13 The records and discussion with service users and staff identified that opportunities to access the community are provided. These include visiting the cinema, places of interest (such as the Sea life centre) and shopping. The inspector raised concern at the way in which such activities were funded, as at present service users have funded themselves and up to two staff required to support them. This has been raised with the provider, and Birmingham Contracts Department for further exploration. It was positive to hear that service users and staff have started to think about holidays, and had been to collect brochures. The inspector again raised concern regards the way in which it is planned these will be funded. The frequency with which community activities are planned and undertaken has increased for all service users. The weekly planners did not accurately cross reference to the daily records made, and no reason as to why planned activities had not gone ahead was available. A requirement of the report is that this area be audited, to ensure shortfalls can be addressed to enable service users to undertake the activities they have chosen with greater frequency. The rota and observation identified that staff competence is key to enable service users to access the community. At the time of inspection, and on other days sampled on the rota the skill mix of staff was not adequate to safely support service users in the community. For approximately four hours the inspector did not consider the ratio of staff provided in the home to be adequate either. Service users records identified that they are supported to stay in touch with their family, and with people important to them. During the visit the inspector identified restrictions made on service users liberty that had not been documented, or planned in their record of care. Service users accommodated at 19 Wheelwright Road are all of different cultural heritage. It was positive to see that this had been noted in the service users plans, and some examples of service users being supported to undertake specific activities relevant to their culture and gender were apparent. It was not evident in the activity or care planning that this need was being consistently addressed. The quality of food provided in the home has continued to improve. The range of fresh products available was positive. It was not apparent that the current diet is meeting service users needs regards loosing or maintaining a healthy weight. It was noted that healthier alternatives including low fat custard, fruit in juicenot syrup, and low fat cheese for example could easily substitute existing products, without limiting service users choice. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 Quality in the outcome area of healthcare is poor. Quality in the outcome area of medication and personal care is adequate. This judgement has been made using available evidence including a visit to this service. Personal care needs are well met, and service users appeared well presented. Medication is well managed ensuring service users get the right medication at the right time. Service users challenging behaviour is not well planned for, or effectively recorded and evaluated, which results in needs in this area being poorly met. Some specific healthcare needs require further assessment and planning to ensure service users needs are well met. EVIDENCE: During the visit the inspector was pleased to meet all three-service users. They had been supported to undertake personal care to a high standard. This included opportunities for the women, to undertake hair and nail care, and for the men to shave. Service users healthcare records showed that routine appointments with the GP, optician, chiropodist and dentist were being offered. It was positive that medication reviews had been undertaken with the GP, and that diabetic checks had been undertaken as required. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 15 The inspector noted one service user was not wearing her prescribed glasses. Staff were unsure if these were lost or broken, and it is required that action to obtain a replacement pair be urgently undertaken. Behaviour management remains an area of serious concern. The inspector was pleased to see some specialist input had been sought regards this. The report of the assessment undertaken was sent to Caretech and the home in January 2006, it identified that the staff did not know how to communicate with the service user, that the environment did not meet her needs, that the daily timetable was not followed, that staff were unaware of how to help the service user relax, that inadequate opportunities were provided for leisure, that early intervention signs were not recorded, and that person centred planning had not been undertaken. A series of recommendations were made. It was only evident that one (to purchase a digital camera) had been undertaken Tracking the number of incidents, which had occurred, and establishing the number of near miss incidents was very difficult. Records of physical intervention, and incident records were not stored together in the main file. From these records tracking the effectiveness of planned interventions, and establishing a baseline of incidents was not possible. Two service users tracked are both overweight. In one persons file weight records had written beside them “scale not accurate”. It was of concern this plan had been reviewed in January 2006, and no changes made despite the current plan being ineffective. Key areas of needs about nighttime needs, autism, challenging behaviour and sexuality had not been planned. In the file of female service users information regards menstruation were not available. Discussion with staff identified possible problems in this area, yet no consultation with a GP had been undertaken. Medication management was good. The records and medicines available, tallied, and records had been signed to evidence administration. It was recommended the location of the sharps box be reviewed to minimise the risk of a sharps injury in the event of the box falling, or being knocked off. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 Quality in the outcome area of complaints is good; quality in the outcome area of protection is poor. Caretech has a robust complaints procedure; ensuring concerns about the service can be raised and addressed. Service users behaviour places them at risk of harm, and this remains poorly planned for and met. EVIDENCE: There has been one complaint made about this service since the last inspection. This was investigated by Caretech and found not to be upheld. The Caretech policy for complaints is robust, and if followed would ensure concerns are thoroughly explored. The service users are at risk from each other, and observation and evidence available in the home did not evidence this risk was well addressed or managed. Incidents of service user to service user abuse has occurred, and it was not evident that the service responded robustly to take action that would prevent such incident re-occurring. It was of concern to read in February’s staff meeting that one service users pubic hair had been shaved by staff. This must be reported to the placing Social Care and Health office as a potential Adult Protection matter, and the provider must ensure staff are aware of the inappropriateness of this. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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, 25, 26, 27, 28, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Caretech have undertaken some redecoration of the premises since the last inspection. The majority of the home remains in need of updating to ensure it is homely, safe and comfortable. EVIDENCE: The home has been subject to some redecoration since the last inspection. The halls stairs and landing all appear much brighter, and cleaner. The inspector was pleased to observe all three-service users rooms. These were very individual to each person, and contained items known to be important to them. The premises remain in need of investment. The dining room table was observed to be heavily worn. This requires replacement. There were four dining chairs available at the time of inspection, which did not facilitate staff sitting to eat with, or support service users at mealtimes. The dining room, second reception room, and lounge all require redecoration. The ground floor WC was clean and well decorated. The light chord needs to be cleansed, and arrangements made to keep this so. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 18 The kitchen was well maintained, and good food hygiene practices were observed. The first floor bathroom has been repainted since the last inspection. The room remains unattractive, and has an appearance of being heavily worn. Paintwork, the bath panel, toilet cistern and tiling continue to require upgrading. The arrangements for exiting or entering the home in event of an emergency were again raised with staff, and the inspector remains concerned that the patio doors are locked with a key, which could hinder exit in event of an emergency. Records of food core temperatures, and fridge freezer temperatures had been maintained. The Environmental Health team inspected the home in February 2006, and received a mainly positive report regards this. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff had a good relationship with service users. Service users are mainly protected by robust recruitment practices. Staff had received some training to enable them to meet service users needs. Staff had received some formal supervision; this was not with the frequency required, to ensure they are able to meet service users needs. EVIDENCE: During the inspection the interactions between service users and staff were observed or overheard to be positive, supportive and inclusive. Some good examples of staff engaging with service users, and trying to communicate were observed. Three staff files were assessed. Staff had all the recruitment records required, but not all application forms were fully completed, to evidence the person’s work or training history in the past ten years. The inspector was concerned about the skill mix of staff on duty at the time of inspection. Two experienced staff were on duty with one staff who was on induction. This staff member had no previous experience of care and had not received mandatory training, including training in challenging behaviour. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 20 One of the experienced staff members was out of the home for approximately four hours, while supporting another service user to college. During this time the remaining two service users were not supported by an adequate number of competent staff, and the staff on duty could not have safely managed an incident of challenging behaviour. The inspector considered this situation placed service users, staff and visitors at risk of harm, as well as preventing service users being able to undertake any community based activity. One staff had received a recent supervision. Another person had not been supervised since November 2005, and the other staff was a recent starter. It was positive that staff were being provided with LDAF induction. A selection of training certificates were available in the staff files. These did not evidence that staff had received all mandatory training to the required level. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. It is anticipated the management of the home will improve, as a manager has been appointed. Caretech has implemented a quality assurance system, which enables them to monitor and improve the service provided. Record keeping needs to be reviewed to ensure records of care are up to date, and accessible. Health and safety is generally well maintained, but urgent work is required to bedroom doors to ensure adequate fire protection. EVIDENCE: This home has been without a registered manager for four years. The CSCI considers it positive that a manager has been recruited, and now requires application for registration is made. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 22 Caretech has implemented a system of quality assurance. It was apparent from staff meetings that this had been commenced, but records showing the outcome of the exercise were not available. There was a current certificate of insurance and registration on display. The service manager undertakes monthly regulation 26 visits. Records of these are forwarded to the CSCI, and show a thorough visit is made. Service users money was assessed. The money available tallied with records and receipts available. The inspector did not track receipt of benefits. The way in which community based activities are funded was of concern, and has been raised with the provider and Birmingham contracts for further exploration. Service users, staff and visitors are protected by the correct health and safety tests being undertaken. Records showed that the emergency lighting had not been checked in March 2006, and an immediate requirement regards this were left at the home. The doors on bedrooms did not well fit the frames, and significant gaps were observed between the top and bottom of the door. These wouldn’t provide adequate protection in event of a fire and it has been required these be urgently reviewed with West Midlands Fire service. Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 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 X 2 X 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 1 ENVIRONMENT Standard No Score 24 1 25 2 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 1 X LIFESTYLES Standard No Score 11 2 12 2 13 1 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 X 2 X 2 1 X Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 24 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 YA19YA6 Regulation 12(1) Requirement Unmet from last two inspections. Appropriate behaviour management plans that contain individual proactive strategies must be developed. Service users plans must make clear how support and care is to be offered. Unmet from last two inspections. A user-friendly format for maintaining service users records must be developed. Unmet from last inspection. Care documents must contain clear guidance on how care needs are to be met. Unmet from last two inspections. Evidence of consultation with service users or their representatives must be available in the service users plans. Requirement re training outstanding from the previous two inspections. DS0000065018.V288374.R01.S.doc Timescale for action 01/07/06 2 3. YA6 YA6 12(1)(a) 17(1) 01/07/06 01/08/06 4. YA6 12(1)(a) 15 01/07/06 5. YA8 12(2)(3) 01/07/06 6 YA8 18(1)(a,c) 01/07/06 Wheelwright Road, 19 Version 5.1 Page 25 7. YA8 12(2) 8. YA9 13(4)(a-c) 9. YA9 13(4)(a-c) 10. YA9 13(4)(a-c) 11. YA13YA23 13(6) 12. YA14 16(2)(m-n) 13. YA16 12(4)(a-b) Staff must be trained and provided with the required resources to communicate with service users. Evidence of the action taken in response to ideas raised by service users must be provided. Unmet from the last inspection. Risk assessments must contain consistent information, and practice must be consistent with the assessment documents. Unmet from the last inspection. Restrictions made on service users must be kept under review, and action taken to minimise the impact these have. Unmet from last two inspections. Risk assessments that reflect current risks and practice must be available in the home. The arrangements for funding of activities and holidays must be reviewed, and written evidence that this is compliant with the Birmingham City placement contract obtained. Unmet from last two inspections. A choice of interesting and varied activities both in the home and community must be available for service users each day. Unmet from the last inspection. Service users must be offered opportunity to maintain and develop their spiritual and cultural beliefs. DS0000065018.V288374.R01.S.doc 01/06/06 01/07/06 01/07/06 01/07/06 01/08/06 01/07/06 01/07/06 Wheelwright Road, 19 Version 5.1 Page 26 14. YA17 16 15. YA19 12(1)(a) 18(1)(a) 16. YA19 12(1)(a) 13(1)(b) 17. YA19 12(1)(a) 18. 19. YA19 YA19 12(1)(a) 12(1)(a) 20. YA19 12(1)(a) 21. 22. YA19 YA23 12(1)(a) 13(6) The food offered must be reviewed to ensure it is consistent with supporting people achieve and maintain a healthy body weight. Unmet from the last inspection. The home must be resourced and staffed to meet service users needs. Unmet from the last inspection. Incidents of challenging behaviour must be fully recorded, and reported. Review of these records must be undertaken to direct and inform care practice. Unmet from the last inspection. Service users must be supported to achieve and maintain a healthy weight. Plans must be kept under review for effectiveness. Plans must be developed to underpin all service users known needs. A review must be undertaken of service users female health, and any noted concerns followed up with the GP. Arrangements must be made to ensure accurate weight measurement and recording is undertaken. Service users must be offered aids and adaptations such as glasses. Unmet from the last inspection. The provider must ensure all reasonable action measures are undertaken to protect service users from abuse, neglect and self-harm. DS0000065018.V288374.R01.S.doc 01/06/06 01/06/06 01/06/06 01/08/06 01/07/06 01/06/06 01/06/06 01/06/06 01/06/06 Wheelwright Road, 19 Version 5.1 Page 27 23. YA24 23(2)(b,d) 24. YA24 23(2)(g) 25. 26. YA30 YA27 23(2)(d) 23(2)(b,d) 27. YA28 23(2)(b) 28. YA33 18(1)(a) 29. 30. YA34 YA36 19 18(2) 31. YA37 8 9 23(4)(b,c)(iii) Unmet from last inspection. Refurbishment of the communal areas must be undertaken, in a style consistent with service users age, gender, cultural heritage and behaviours. . The dining room table must be replaced or upgraded, and adequate dining chairs must be provided. Light chords in the bathrooms must be maintained in a clean condition. Unmet from the previous inspection. The first floor bathroom must be redecorated and suitable window covering provided. Consideration must be given to landscaping and planting the garden to provide a more attractive recreational area for service users. Unmet from the previous inspection. The number of staff on duty must be adequate to meet service users assessed needs and enable access into the community. Staff recruitment records must evidence work history for the past ten years. Unmet from last two inspections. Supervision must take place at least six times a year. These must be formal and minutes taken and a record given to the member of staff. The acting manager must make an application for registration with the CSCI. How entry and exit in the event of an emergency would 01/08/06 01/06/06 01/06/06 01/08/06 01/08/06 01/06/06 01/06/06 01/07/06 01/06/06 32. YA42 01/06/06 Page 28 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 33. YA42 23(4)(c) 34. YA42 23(4)(c) be undertaken must be explored, and action required undertaken. Bedroom doors must be reviewed with West Midlands Fire service, and action taken as required ensuring adequate fire protection is offered. Emergency lighting must be tested monthly, and a record of such maintained. 01/06/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3 4. Refer to Standard YA6 YA8 YA8 YA12 Good Practice Recommendations It is recommended that Person Centred Planning be undertaken with service users to address peoples changing needs and aspirations. It is recommended that information about service users be presented in an accessible format. Daily records should be focussed on the service users experience of the day, and not that of staff. It is recommended that household activities be included in the service users support plans, so that progress made and the effectiveness of the strategy can be monitored and evaluated. It is recommended that activities be audited to establish why they didn’t they occur, and such information used to develop the service. It is recommended that the sharps box be re-located to reduce the risk of sharps injuries. 5. 6. YA13 YA20 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 29 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 Wheelwright Road, 19 DS0000065018.V288374.R01.S.doc Version 5.1 Page 30 - 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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