Inspection on 21/03/08 for 218 Stourbridge Road

This is the latest available inspection report for this service, carried out on 21st March 2008.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

218 Stourbridge Road 19/12/05

218 Stourbridge Road 04/08/05

218 Stourbridge Road 17/03/05

218 Stourbridge Road 14/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Stourbridge Road, 218 218 Stourbridge Road Bromsgrove Worcs B61 0BJ Lead Inspector Gillian Goldfinch Key Unannounced Inspection 21st March 2008 11:30 Stourbridge Road, 218 DS0000061839.V355663.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 Stourbridge Road, 218 DS0000061839.V355663.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. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stourbridge Road, 218 Address 218 Stourbridge Road Bromsgrove Worcs B61 0BJ 01527 579611 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) Worcestershire Mental Health Partnership NHS Trust Mr Wayne Stanley Casey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th February 2007 Brief Description of the Service: 218 Stourbridge Road is a traditional detached house approximately 1½ miles from Bromsgrove town centre, providing a home for up to five people with mental health needs. There is easy access to public transport and the town centre, including the Bromsgrove Mental Health Resource Centre. The home includes ground floor bedroom and bathroom facilities. Service users have their own furnished bedrooms with two lounges (one where smoking is allowed), a dining room and kitchen shared by the household. The home aims to provide a homely environment promoting independence and dignity. Service users receive care and support to live as ordinary a life as possible in the community. The manager, Wayne Casey, began working in the home at the end of January 2005, and was registered in June 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual for the Trust is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. Written information about the home is available in a service users’ guide and a statement of purpose. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality. This was a full inspection of the home to look at how the home is performing in respect of the core national minimum standards (the report says which these standards are). We call this type of inspection a key inspection. The inspection visit was unannounced and took place over one day. The Home completed an Annual Quality Assurance Assessment prior to the inspection and the information provided in this was taken into account. The inspection included time spent with the care manager assessing the Home’s progress in meeting the National Minimum Standards and in implementing the requirements that were made as a result of the previous inspection. Time was spent with those who live at the home and some staff. Throughout the inspection there were opportunities to observe and overhear staff contacts with people who live in the Home. Documentation was checked, including the care records of people who live at Stourbridge Road, and some staff files. Copies of policies and procedures were made available. What the service does well: The home provides a comfortable and homely environment. The home supports those who live there to access appropriate educational, leisure and occupational facilities. It provides a flexible staff rota to make sure individuals can access evening activities with support from staff. The service responds well to the requirements and recommendations made by the commission for social care inspection. The service supports individuals healthcare needs both physically and psychologically and makes sure they have access to community health care. The home actively encourages the involvement of the relatives and friends of those who use the service in accordance with the wishes of each individual. Record keeping in the home is efficient and well organised. Stourbridge Road, 218 DS0000061839.V355663.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. Stourbridge Road, 218 DS0000061839.V355663.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 Stourbridge Road, 218 DS0000061839.V355663.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates a thorough admissions procedure. An appropriate assessment of the needs and aspirations of those who use the service had been carried out. EVIDENCE: Pre-inspection information provided by the home showed there had been no new admissions since January 2005. The registered manager stated that before each admission, a comprehensive community care assessment is completed. A senior member of the staff team will assess the prospective service user in their current environment. This would include gathering information relating to their background, needs and aspirations, likes and dislikes. This information would be gathered from all those involved in supporting the prospective service user. This may include other relevant professionals, family members, previous carers and the individual themselves. The individual and relevant others are encouraged to visit the home on a Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 9 number of occasions to meet with staff and others living at the home. These visits are planned to take into account various times of the day and evening, an overnight and weekend stay would be included during these visits with all meals provided. Individual’s admitted in 2005 had full assessments of their needs before admission. A sample of care records were checked and ongoing assessments of individual needs were seen, these were being reviewed regularly and translated into care plans. Individuals who spoke with the inspector were all fully aware that their needs were assessed and all felt included in this on-going process. One individual commented: ‘I look at my needs, and if they have changed, when I look at my care plan with my key-worker’. Stourbridge Road, 218 DS0000061839.V355663.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. Those who use the service were aware of the contents of their plan of care, encouraged to make decisions about their lives and supported to take risks as part of an ordinary lifestyle EVIDENCE: Samples of individual care records were inspected. Care records were stored on computer but were fully available in paper form. Each individual record was found to contain a clear account of assessed and changing needs. These were being reviewed monthly with the individual and their key-worker. A key worker is a designated member of staff who has some responsibility, under the guidance of the registered manager, to ensure the care needs of specific individuals are being met. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 11 A more formal review is held every six months, involving other important people in the life of the individual. Evidence of this included other professionals, friends, advocates or family members. Pre inspection information received from the registered manager stated: ‘Six monthly meetings take place where the resident is able to choose who attends. The residents are involved in a variety of activities in and outside the home. During care planning meetings the resident is present and is able to contribute to the care they receive.” Those individuals who spoke with the inspector were fully aware of their care plans and stated they felt included in and part of the planning of their care. Overall, individuals were able to make their own decisions. There was no evidence of restrictions on individual choice or freedom except where an assessed risk had been identified and documented. An example of this was recorded in respect of an individual smoking in the home in undesignated areas. A contract had been drawn up with the individual and was being regularly reviewed. Weekly resident meetings take place in which joint decisions are made about topics such as the weekly menu and joint outings. One individual commented: “We choose our menu at the meetings and help with the daily cooking”. The registered manager stated: “All residents choose and devise a weekly menu and they complete a shopping list, staff support them in weekly shopping trips to purchase the homes food as per list.” Some individuals had challenging and complex needs. There was evidence in the care records that any risks associated with identified needs were being appropriately assessed, recorded and reviewed. Individuals who spoke with the inspector confirmed they were able to participate in ordinary activities such as going out alone, carrying out household tasks such as cooking and laundry and go swimming. Staff assessed the risks and took appropriate action to reduce them. The home had a procedure in place for use in the case of missing persons, this was readily accessible to staff. Stourbridge Road, 218 DS0000061839.V355663.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 good. This judgement has been made using available evidence including a visit to this service. Staff encouraged and supported individuals to be involved in various occupational, educational and leisure activities. Individuals were able to maintain contact with their relatives and friends. Individuals were encouraged to participate in the daily running of the home and to develop their social and domestic living skills. EVIDENCE: There was evidence that individuals were able to participate in appropriate activities. Care records showed details of these activities. Some activities were undertaken within the home and others within the community. Those using the service were able to participate in everyday community activities both during the day and at weekends. Those individuals who spoke with the Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 13 inspector talked about going to the cinema, out for meals, attending college and going to play bowling. The home kept a record of activities, including those offered and declined, for each individual. Records seen showed that efforts were regularly made to enable those using the service to have access to enjoyable activities. The registered manager had continued to work hard at encouraging the involvement of relatives and friends both in activities which take place in the home and the care of individuals. This had taken the form of inclusion of relatives and friends in care reviews and family days held at the home e.g. a celebration of Mothering Sunday. In addition, the home had begun to hold relatives’ meetings every 3 months, giving a valuable opportunity for relatives to keep involved and in touch with the home. Those individuals who spoke with the inspector stated their family and friends were always welcome by staff and that there was plenty of opportunity for spending private time and space with family and friends within the home should they wish to. Individuals were also clear that they could refuse to see visitors to the home should they wish to and be supported by staff in doing so. Individuals stated they did not feel restricted by the daily routines of the home. Those who spoke with the inspector confirmed they received their post unopened and that staff were available to help with the contents of letters should such help be required. Individuals had keys to their bedrooms and confirmed that staff always knocked on bedroom doors and waited before entering. The inspector observed staff interacting with individuals in a relaxed, friendly and sociable manner. Individuals confirmed they had some responsibility for housekeeping tasks, on a rota basis. These included keeping bedrooms clean and tidy, laundry tasks and cooking. With assistance from staff individuals participate in the weekly shopping for the home and decide in their weekly meetings on the menu for each week. The kitchen was seen and found to be well stocked with provisions, fresh fruit and vegetables. Stourbridge Road, 218 DS0000061839.V355663.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 good. This judgement has been made using available evidence including a visit to this service. Staff suitably supported the health and personal care needs of those who use the service. The control and administration of medication was being safely managed. EVIDENCE: The personal support, physical and emotional health care needs of individuals were detailed in their plans of care. The registered manager stated on the pre inspection information: “The home has person centred care plans for each resident, including a comprehensive physical health care plan. Each resident is registered at a general practice of their choice and has access to the services the practice has to offer, for example annual health checks, diabetic care and routine Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 15 appointments. Each resident has access and support at optician and dental checks and a visiting chiropodist visits every eight to ten weeks” Plans of care seen during the inspection adequately addressed individual health care needs, were well maintained and were up to date. Individuals who spoke to the inspector felt their health care needs were well provided for and that they had access to health care facilities as required. Some individuals required some help and support with their physical health care needs. Staff who spoke with the inspector were able to describe how any such support is offered in ways that protect the dignity of the individual requiring the support. Support was provided for individuals to access community mental health facilities. Mental health reviews were held as necessary with community mental health professionals. Any such appointments were monitored and recorded. The home had written policies and procedures in place for the administration of medication. The inspector checked the entries on the medication administration records to ensure requirement made at the previous inspection had been implemented. The requirement was being met; the records were well maintained and were clear and accurately completed. Likewise, requirement made for medication given to be consistent with instructions on the medication labels and medication administration record sheets was checked and was met. Some individuals looked after their own medication, having been assessed as safe and capable to do so. They had support from staff with this, and safe storage areas. Staff had received training in the safe handling and administration of medication. The home had access to pharmacy advice via the trust pharmacist. Stourbridge Road, 218 DS0000061839.V355663.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. The home had policies and procedures in place to enable those who use the service or their representatives to raise concerns or complaints. The home had appropriate policies and procedures in place to protect those who use the service from abuse, neglect or self-harm. Staff had received training in the protection of adults from abuse, neglect or self-harm. EVIDENCE: The home operates a thorough policy on responding to concerns or complaints, this included CSCI (Commission for Social Care Inspection) contact details and gave an assurance that any concern would be dealt with within 28 days. The home kept a record of complaints or concerns, and of the action taken in response to them. No concerns or complaints had been received by CSCI concerning the home. Individuals who spoke to the inspector confirmed they felt able to talk to staff about any concerns they may have. No relatives had needed to make complaints, Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 17 The home had a suitable policy on Protection of Vulnerable Adults. All staff had received training in this area. The registered manager confirmed on the pre inspection information that some staff were due an update on there training within the next twelve months. There had been no concerns about abuse in the home. Staff who spoke with the inspector were clear about what would constitute abuse and of what action to take to protect those using the service. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s premises are suitable for its stated purpose. The home provides a homely and comfortable environment. The garden area does not provide privacy for those living at the home. The home was clean and hygienic. EVIDENCE: The inspector made a tour of the home and was shown four of the five bedrooms by four individuals living at the home. These were highly personalised and individuals confirmed they had been involved in decisions about the décor and content of their personal space. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 19 The environment was domestic in style and homely. Most of the areas were well maintained and it was pleasing to see that requirement made at the previous inspection relating to decoration and refurbishment of a bathroom had been met. Some areas still required decoration. There was torn and peeling wallpaper in the dining area, which is in need of replacement and redecoration. (See Requirements). The manager stated on the pre inspection information that the Trust had yet to implement a rolling programme for the redecoration and refurbishment of the building. Other improvements made since the last inspection included a new patio area, new outside furniture and a barbecue area. These were to the rear of the house. There is an extensive area to the front of the property, which could also provide an additional garden space. At the moment this area is open with no fencing and therefore no privacy for those living at the home. It is also used as a thoroughfare for the general public, which is not in keeping with private housing. A comprehensive health and safety/risk register has been developed to assess any risk to the whole environment of the home. The registered manager stated that the Trust was not always prompt in taking action to address identified risks and that getting work done often took an unreasonable length of time. Although there was evidence that work does eventually get undertaken this was not the first time this matter had been raised during inspection visits. Identified risks must be addressed promptly to ensure the safety of those who live and work at the home. The home was close to local amenities, local transport and relevant support services to suit its purpose and the needs of those living in it. The laundry was suitably sited and equipped. Sluice facilities were not needed in the home. There was a policy on infection control. The home was clean and free from odours on the day of the inspection. Those individuals who spoke with the inspector were happy with their accommodation. One person stated she would like an ottoman for her room to use as additional storage. The registered manager was informed of this request. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient numbers of competent and qualified staff to meet the assessed needs of those who use the service. Those living at the home were supported and protected by the home’s recruitment policies and procedures. EVIDENCE: The inspector spoke with three of the support staff. All had a clear understanding of the needs of those who use the service. There were opportunities throughout the inspection to observe staff interacting with individuals who live at the home; communication appeared relaxed and comfortable. Staff were interested, motivated and committed to their work. The manager stated on the pre inspection information that out of the five support workers working in the home three had attained NVQ level 3 in promoting independence and the remaining two were working towards Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 21 completion of the award. The registered manager holds an NVQ assessor award. A training plan was in place showing which staff had undertaken training and which training was planned or booked for the next year. Most basic training was in place. Staff had completed first aid, medication and food hygiene training. Most staff had been trained in infection control, manual handling, equality and diversity, protection of vulnerable adults, MAPA (management of actual or potential aggression). Some staff had undertaken training in other relevant topics such as hearing voices, schizophrenia and selfharm. The registered manager stated on the pre inspection information that all staff have a personal portfolio with a training record. Each staff member receives an annual staff development review with the manager; who has been trained in how to deliver staff development reviews. A sample of staff records were looked at and found to contain the required information. This included written application form, two written references, a photograph of the staff member a copy of the terms and conditions of employment, a copy of the contract of employment and evidence that appropriate criminal record bureau, (CRB), checks had been undertaken to ensure the safety of those living in the home. The Trust was in the process of repeating criminal record checks on existing staff. There had been no new staff recruited to the home since the previous inspection. The registered manager stated he would ensure that all required information was available in the home before any newly recruited staff commenced employment. This was a requirement made at the previous inspection. The registered manager is working towards developing ways of including those who use the service in the recruitment of any new staff. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 22 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. Individuals who use the service benefit from a well managed home. The home has adequate quality assurance and quality monitoring systems designed to monitor, review and develop the service. The registered manager works hard to ensure that the safety and welfare of those who use the service is promoted and protected. EVIDENCE: Those who live and work at the home spoke extremely highly of the registered manager and the commitment he shows to continually developing the service for the benefit of those who use it. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 23 The home manager has gained his RMA-NVQ4 and is a first level nurse in the speciality of mental health. He has over twenty-five years experience with sixteen years experience of working as deputy/manager of a regulated care home. The registered manager mainly worked office hours during the week to keep up with management work, but every other weekend worked on care duties within the home to keep in touch with service users. Requirement made at the previous inspection for the quality assurance system being developed at that time to be implemented had been met. Much work had been undertaken since the previous inspection in developing quality assurance and quality monitoring systems for the home. These are now in place and aim to measure success in achieving the aims, objectives and statement of purpose of the home. These systems include mapping the services provided against the national minimum standards. Seeking feedback through the use of questionnaires from all parties interested in the home including those who use the service, relatives/ friends and other professionals. This is done through the use of written surveys/questionnaires and through verbal feedback. A six monthly service review is now held from which a quality monitoring report is produced. The purpose of the review is to assess progress made during the previous six months in meeting key objectives. Areas covered by the review include staffing, concerns and complaints, health and safety, aims and objectives. Information collated from the review is used as part of a systematic cycle of consultation, planning, action and review. The home has an annual development plan, which forms part of, and is linked to, the quality assurance and monitoring systems. The plan provides a way in which the service is able to identify areas of strength and weakness, create an action plan and monitor improvements based on feedback from consultation or auditing processes. The home’s policies and procedures cover the necessary areas in relation to the health, safety and welfare of residents and staff. The registered manager stated that requirement made at the previous inspection relating to electrical safety had been met. Electrical safety checks on equipment in the home, PAT tests, had been carried out on 4/2/08. One leaking kettle had been replaced. Fire records were checked and found to be in order. Requirement made at the previous inspection for staff to undertake a fire drill each year was being implemented. Requirement made by the Fire Authority in 2006 for remedial Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 24 work to be carried out in the home to the fire alarm system had also been met. The registered manager stated he was awaiting the removal of one old fire panel, which was no longer part of a zoned area. A fire safety risk assessment was in place. The fire officer from the NHS Trust visits twice yearly to risk assess and to undertake training on fire safety for both staff and those who live in the home. Five of the support workers and the deputy manager are trained fire wardens. Requirement made at the previous inspection for the emergency lighting to be serviced and maintained was being met. The NHS Trust in 2006 undertook an infection control audit no issues were raised and the home scored a total of 97 percent. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 25 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 3 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 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA24 Regulation 23 Requirement Action must be taken to ensure that the decorative state of the dining area is improved. Specifically this means: The room must be redecorated to replace the existing paint and wallpaper. Timescale for action 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations The home should give consideration to training service users to enable them to take a greater part in staff recruitment. Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Stourbridge Road, 218 DS0000061839.V355663.R01.S.doc Version 5.2 Page 28 - 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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