Inspection on 10/10/05 for Wood Lane, 135

This inspection was carried out on 10th October 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wood Lane, 135 13/06/08

Wood Lane, 135 13/07/07

Wood Lane, 135 13/02/07

Wood Lane, 135 02/03/06

Wood Lane, 135 04/03/05

Wood Lane, 135 19/08/04

Wood Lane, 135 16/03/04

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 Wood Lane, 135 Handsworth Birmingham West Midlands B20 2AQ Lead Inspector Gerard Hammond Unannounced Inspection 10th October 2005 12:30 Wood Lane, 135 DS0000016881.V259360.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 Wood Lane, 135 DS0000016881.V259360.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. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wood Lane, 135 Address Handsworth Birmingham West Midlands B20 2AQ 0121 523 5547 0121 523 5547 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 Damien Crossan Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users must be aged under 65 years Service users must have a learning disability. The home may accommodate one named service user over the age of 65 years with a learning disability. The home must periodically review that it can still meet the needs of the named service user over 65 years, and a record of these reviews must be retained in the home. That Damian Crossan obtains the Registered Managers Award or equivalent by April 2005. 04 March 2005 5. Date of last inspection Brief Description of the Service: 135 Wood Lane is registered to provide accommodation, care and support for four people with learning disabilities. The house is a two-storey semi-detached property and is located in a pleasant and well-established residential area in the Handsworth district of Birmingham. Accommodation is provided in two single and one shared bedroom. One of the single rooms is on the ground floor. There are two bathrooms in the house, one on each floor. Downstairs there is also a lounge, separate dining room, kitchen and laundry. Upstairs, in addition to the shared and single bedrooms, there is a small office. There is an attractive enclosed garden to the rear of the property, and this has a lawn, planted borders and a small patio area. At the front of the house is a paved area with limited off-road parking. There are local shopping facilities within walking distance, and main bus routes also run close by. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Registered Manager was not on duty on the day of the inspection visit, so the Service’s representative that day was the shift leader (Senior Care). She was formally interviewed, and two other members of staff were seen informally. The Inspector met with all the residents, but it was not possible to interview them or gather their views directly, due to their learning disabilities and communication support needs. Direct observations and sampling of records (including personal files, care plans, safety records and previous inspection reports) were used for the purposes of compiling this report. A tour of the building was also completed. What the service does well: What has improved since the last inspection? Attempts have been made to meet some of the requirements made at the time of the last inspection. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 6 There is evidence that some improvement has been made to staffing levels during the week, as there are now days when the Manager is on duty with two other members of staff. It is clear that a lot of work is going on within the Organisation to improve the quality of assessing and care planning, and records contain some good quality information about people’s strengths and support needs, and how these might be met. Attempts have also been made to introduce person-centred approaches into this work. 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. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 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 Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Residents’ needs are appropriately assessed. EVIDENCE: There have been no admissions since the time of the last inspection, and the current group of residents has been together now for several years. There is a lot of assessment information on people’s personal files, and the Organisation has recently introduced a number of changes into the way in which assessment and care-planning information is recorded and presented. Inevitably, this is taking time to implement fully. It was noted that one resident had a completed ELSI (Everyday Living Skills Inventory) on file, but it was neither dated nor signed by the person who filled it in. This in itself may seem a small thing, but accurate dating of such information is important, so as to set data in context when assessments are reviewed. It is recommended that full use be made of this good work in informing future care planning. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 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 & 9 Residents’ needs are reflected in their plans, but some development is required so that the management of essential information is improved. Staff support residents to make decisions about their lives. Enhancing communication opportunities might have a further positive effect on this. Responsible risk taking is encouraged so as to enhance people’s independence, but risk assessments are in need of some development. EVIDENCE: In general terms, the resident group in this house are all people with complex and high-level support needs. It should be acknowledged that the management of care-planning and risk assessment information in such cases is not a simple task. The sheer volume of data that has to be maintained makes this far from easy. There is clearly a lot of activity going on currently in the area of care plan development, and as reported earlier, the Organisation is introducing new systems for recording and presenting information. It is recommended that care plans are numbered and indexed, to help make it easier to locate specific information quickly. Plans need to include sufficient Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 10 detail so that the reader can understand exactly how support should be given. One person’s plan of support for going to bed indicated that the resident liked his room for changing and sleeping and that people should respect the fact that his room is “his territory”. However, the plan did not show whether or not he needs help to get undressed, to have support finding and putting on nightclothes, getting a wash, closing the curtains, preferences for nightlight, particular routine, and so on. It may well be that this information is well known to the current staff team, but this sort of detail should be recorded in his plan. There is evidence of efforts to adopt person-centred approaches and also to set some goals, and this should be commended. This also requires some development, so that goals set have outcomes that can be measured. It is also recommended that targets are specific and time limited. For example, a longterm goal “to maintain as much independence as possible” should indicate how this will be achieved and show what the indicators of this might be. Goals should be evaluated at review. Whole care plan reviews should take place at least every six months, with written records kept, indicating who takes part and how decisions are made. Sample checking of personal files also found a range of risk assessments in place, indicating that proper consideration has been given to responsible risk taking, so as to encourage people’s independence and enhance opportunities for learning. As already indicated with care plans above, it is recommended that risk assessments are indexed and numbered: they should also be directly cross-referenced to the care plan(s) to which they relate. There seems to be some confusion about risk assessing and care planning. For example, some information contained in control measures to minimise or eradicate identified hazards, was not subsequently transferred to care plans. In the case of the resident mentioned above, (whose plan for support at bedtime needed development) there was information contained in risk assessments that should have usefully supplemented the plan, but this was “hidden” and not easy to locate. Staff were observed supporting residents to make choices about what they wanted to do, during the course of the inspection visit. People’s learning disabilities and their support needs do restrict the nature of some of the choices open to them. It is recommended that individual care plans contain detailed communication guidelines, and that these continue to be developed. Guidelines should be placed prominently on personal files so as to encourage their use and development. It should be acknowledged that there was evidence around the house of efforts made to support residents’ communication, such as pictorial aides, and practice should be encouraged and extended. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Residents are able to take part in appropriate activities and to access the local community, but the range and quality of opportunities needs to be reviewed, and the standard of activity recording improved. People are supported to keep in touch with families and friends. Staff respect residents’ rights and encourage their independence in their dayto-day lives. People in the house have access to a diet that is sufficiently balanced and nutritious. EVIDENCE: Conversations with staff indicated that residents attend activities arranged through local college networks. In addition, it was said that they also access amenities in the community including local shops, pubs and restaurants, cinema, hairdressers, and local parks. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 12 Sample checking of one person’s activity record for a week indicated four occasions “drive” or “out in car”, cinema, two days entries showed “relaxing, watched TV”, two other days showed activity recorded as “getting plates from dining room” and “getting cup from dining room”. This recording gives a poor impression of the quality of life enjoyed by this person, if this is the sum total of his activities for a whole week. Some thought needs to be given to the purposes of activities undertaken. It is good practice if this is done in conjunction with the setting of goals as care plans are developed. A new format for recording activities was seen: this requires staff to make more detailed entries about the activity undertaken, what choices are made and how, the response to the activity and how judgements about this are made, and who supports the person involved. It is important that detailed records are kept about activities and opportunities for people to participate in them, so as to inform future care planning appropriately. The Manager needs to keep this under review, and to ensure that staff record residents’ activities accurately and in detail. Discussions with staff and previous inspection reports indicate that people are supported to keep in touch with families and friends as much as possible, and in accordance with the wishes of those involved. Residents are encouraged to do things around the house and supported to take part in simple domestic tasks, as much as individual skills and capabilities allow. People were seen clearing up after lunch, and records show that they sometimes help with cooking, making drinks and doing the laundry. Records of meals taken indicate that residents have access to a diet that is sufficiently varied and nutritious. On the day of the inspection, staff and residents had just returned from doing the grocery shopping. Food stocks were seen to be plentiful, and included fresh produce. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Residents receive personal support in accordance with their assessed needs and preferences. In general, people’s healthcare needs are met, but some aspects of essential recording need to improve. Arrangements for storage and administration of medication are generally satisfactory, but instructions regarding some PRN (“as required”) medication need to be put in place so as to ensure safe practice. EVIDENCE: Members of staff were seen giving support to residents in a warm and friendly manner that was appropriately respectful, and showed sensitivity to their needs for dignity and privacy. People living in the house and staff looking after them appear relaxed and at ease in each other’s company. Residents’ personal grooming and attire indicated that basic care is given to a very good standard. One resident’s records showed that he has epilepsy and that this was being monitored. However, the record of epilepsy monitoring was not apparent, and no instructions could be found on his care plan as to its location, though it did state that seizures should be recorded in detail. An immediate requirement Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 14 was made that guidance to staff should indicate specifically where and how recording should be made in this regard. The last inspection report indicated that health action planning had been commenced, in accordance with previous recommendations. It was observed that, on one person’s record, the format for this was in place, but was still largely incomplete. As a matter of good practice, this should now be followed up, and plans completed as appropriate. Records indicate that residents are referred to and supported to attend appointments with members of the multi-disciplinary team, in accordance with their identified needs, including GP, dentist, optician, and speech and language therapist. Arrangements for the storage of medication are appropriately secure. Medication Administration Records were duly completed and contained information about people’s preferences with regard to taking their medicines. There is also a record of the weekly audit of stocks. However, it was noted that there was no protocol in place for one resident’s PRN (“ as required”) Lorazepam, and an immediate requirement was left that this should be rectified. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents’ learning disabilities and communication support needs make it difficult to judge if they consider their views are listened to and acted upon. The service has appropriate systems in place to deal with complaints or concerns. General practice offers residents protection from abuse, neglect and self-harm. EVIDENCE: At the last inspection it was noted that an appropriate complaints policy and procedure was in place, and that the Organisation had also produced this in alternative formats using words and symbols. In addition to this there is a company consultation document called “Letting us know what you think.” The varying degree of learning disability and communication support needs of the people living in this house means that formal complaints systems and procedures are likely to be of limited significance to them personally. Residents are reliant on the vigilance and sensitivity of the care team to changes in their demeanour, behaviour or “body language”, as well as their understanding of their personalities, to alert them if something is wrong. Similarly, the adult protection policy and procedure was assessed at the last inspection and judged to meet the required standard. It was not possible to assess fully whether or not all of the staff team have completed appropriate training (see Standard 35 also) but there was evidence on the rota of some staff attending a course in Adult Protection, and it is known that the Organisation operates a rolling programme of training for all its staff. A copy of the local multi-agency guidelines is on display with other working documents in the kitchen, and it is recommended that the policy is cross-referenced to these. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Residents enjoy the benefit of living in a house that is homely, safe and comfortable. Staff keep the Home clean and tidy, and maintain a good standard of hygiene. EVIDENCE: The house at 135 Wood Lane is a pleasant domestic scale property, and it is clear that staff make every effort to make it a warm, homely and welcoming place for the residents to live in and enjoy. Standards of furnishing and decoration are good. The house is kept clean and tidy, with a good standard of hygiene maintained throughout. There is a separate laundry facility, and this is sited away from the kitchen. The general layout of the house means that it is not a suitable property for people with restricted mobility requiring regular use of specialist equipment. Residents’ mobility needs are kept under review. Of particular note are the efforts made by one member of staff to make the garden space attractive, and this should be commended. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 35 The effectiveness of the staff team is currently compromised by having an insufficient number of staff on duty to meet the assessed needs of the residents at all times. A staff training and development plan is required to assess fully the training needs of the care team. EVIDENCE: In the absence of the Manager, it was not possible to access all staff records. A sample check of the current rota showed that the staffing position has improved since the last inspection. Staff cover during the week showed three on duty (including the Manager when at work) from Tuesday to Friday inclusive. However, on Monday, Saturday and Sunday, there were only two members of staff. The previous inspection report indicated that one resident requires two members of staff to support him on any activities away from the Home. It still remains the case therefore that staff cover is inadequate for those days when only two people are on duty. This means that opportunities for activities outside the home are limited or non-existent on those days, and this is not acceptable. The Organisation should increase staffing levels to ensure that residents’ needs can be met at all times. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 18 An up to date staff training and development assessment and plan is required in order to appraise the current position for the care team. This should show (for each person working at the Home) all training and qualifications undertaken and gained to date. The schedule should also highlight any gaps (including refreshers), and indicate when training is scheduled and who is to deliver it. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: A number of safety records were sample checked during the inspection visit. The fire alarm, emergency lighting systems and fire-fighting equipment have all been serviced, and the fire risk assessment has been reviewed. Weekly checks have generally been carried out on the alarm system, and duly recorded, though one gap was noted. There is evidence that instruction / fire lectures have been given at regular intervals, and fire evacuation practice has been carried out at six-monthly intervals. The record of fire drills should show the names of all who took part. The COSHH file was seen, and contains product data sheets as required. The Landlord’s Gas Safety Certificate is in date, and it was noted that portable appliance testing of electrical equipment is due shortly. Fridge and freezer temperatures have been recorded as appropriate, as have water outlet temperatures. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 20 The accident book was examined and noted to be compliant with current data protection legislation. Completed reports have been removed from the book as required. It is recommended that the counterfoil stub be marked with the date and initials of the person concerned, so that reports can be tracked if necessary. This had been done in some cases, but not all. Wood Lane, 135 DS0000016881.V259360.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 X 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 X 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wood Lane, 135 Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000016881.V259360.R01.S.doc Version 5.0 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1-2) Requirement Care plans must be developed further (as indicated in the main body of this report) to include sufficient detail so that the reader will know exactly how support should be given. Plans should also include goals with measurable outcomes. Develop risk assessments to ensure that control measures are included in care plans, and cross-reference risk assessments to the plan(s) to which they relate, and vice versa. Review opportunities for residents to participate in the life of the local community and to pursue valued activities (see No. 6 below also, Standard 33) Outstanding since 30/04/05. Ensure that appropriate guidelines are in place with regard to managing resident’s epileptic seizures appropriately. This should include instructions with regard to the procedure for recording seizures, and where on the individual’s file this should be done. (Immediate requirement) Devise and implement a protocol DS0000016881.V259360.R01.S.doc Timescale for action 31/12/05 2 YA9 15 (1-2) 13 (4) 31/12/05 3 YA12YA13 16 (2m-n) 30/11/05 4 YA19 13 (1b & 4c) 11/10/05 5 YA20 13 (4c) 11/10/05 Page 23 Wood Lane, 135 Version 5.0 6 YA33 12 (1) 18 (1a) 18 (1a) 7 YA35 8 YA42 13 (4) for the administration of resident’s PRN (“as required”) Lorazepam medication. (Immediate requirement) Staffing levels must be reviewed and increased to meet the assessed needs of the residents. Outstanding since 30/04/05. Produce a staff training and development assessment and plan, as indicated in the main body of this report. Ensure that records of fire evacuation practice include the names of all those taking part. 30/11/05 31/12/05 31/12/05 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 Refer to Standard YA23 YA42 Good Practice Recommendations Cross-reference the adult protection policy and procedures to local multi-agency guidelines. Mark the counterfoil stubs of accident book reports with the date and the initials of the person involved. Wood Lane, 135 DS0000016881.V259360.R01.S.doc Version 5.0 Page 24 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. 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