Inspection on 21/10/08 for Balfour Road (31)

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

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOME ADULTS 18-65 Balfour Road (31) 31 Balfour Road Birkenhead Wirral CH43 4UD Lead Inspector Elaine Stoddart Unannounced Inspection 21st October 2008 09:45 Balfour Road (31) DS0000071746.V369808.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 Balfour Road (31) DS0000071746.V369808.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. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Balfour Road (31) Address 31 Balfour Road Birkenhead Wirral CH43 4UD 0151 651 2032 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) Potensial Limited Angela Bain Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either; whose primary care needs on admission to the Home are within the following categories: Learning Disability , Code LD maximum number of places 4. The maximum number of service users who can be accommodated is: 4 New service 2. Date of last inspection Brief Description of the Service: 31 Balfour Road is a newly registered service. The registered providers are Potensial Limited. The responsible person is John Neil Leighton and the service is managed by the manager Angela Bain. Angela Bain has been approved by the Commission to manage two sites within the area. Balfour Road provides care and personal support for four people with a learning disability. The staff monitor closely the health and care needs of the residents who have access to various health professionals to ensure their health needs are met. The accommodation is provided within a converted large terraced house close to all amenities of Birkenhead. These include shops, leisure facilities and access to local transport systems. The communal accommodation consists of a lounge, kitchen, bathroom and small rear garden area. An office is provided for staff and to store records. All four residents have their own bedrooms. All areas are comfortably furnished to meet the needs of the residents. The home is staffed 24 hours a day by a qualified and experienced staff group. Balfour Road (31) DS0000071746.V369808.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 outcomes. This was an unannounced inspection, which lasted for approximately six hours. During which time the inspector discussed with the manager and members of staff on duty various issues regarding the care provided to the residents. Two of the four residents were present and their views were obtained about the service and care provided at Balfour Road. Throughout the day observation took place on how the residents’ care and support were provided and how the staff interact with the residents. A selection of records was viewed, which included a number of policies and procedures, staff records and care files. A tour of the building took place. Two people were ‘case tracked’. Case tracking means that the inspector concentrates on the care given and experiences of one or more people to get an idea of what is the service is like and how that person’s needs are being met. The main focus of the inspection process was to understand how the staff are meeting the needs of the residents. We also looked at how the staff are supported by the organisation to make sure they have the skills, training and support to meet the needs of the people they care for. The report has been put together using information gathered from a number of sources. This includes details provided in the AQAA (Annual Quality Assurance Assessment. The AQAA was completed by the manager and contained information on the service. The AQAA comprises of two self-questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the people they provide a service for and a dataset that gives basic facts and figures about the service, including staff numbers and training. The AQAA had been completed to a satisfactory standard by the manager. Interviews were conducted with people who use the service and staff during the inspection. ‘Have your Say’ survey forms were sent to people who use the service and to staff. The survey forms enable everyone to given their views of the management and the service provision. A number of comments received have been recorded in the report. The fees range from £577.49 to £772.00 per week dependent on need. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? New service. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 7 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. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 4. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Information is available in a suitable format for prospective residents on the service provided so that they know their needs can be met. EVIDENCE: The AQAA reported that assessments of need, risk assessments and personal developments plans are completed prior to admission. All prospective residents are offered to visit with their families to view the service, spend a day and have a meal and overnight or weekend stays. The statement of purpose, service user guide and welcome to Balfour Road contains information on the service in an easy read format. Equality and diversity is promoted and the information states that All service users are treated as equal to everyone else. Information is available in a user-friendly format with pictures and simple illustrations. The welcome pack is an effective guide for the residents giving practical day-to-day information, for example, how to go to church, where to get a bus and who will help me. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 10 Two residents were case tracked and assessments of need were in place from the placing authorities and an admission assessment by the manager of the service. The needs of the residents were fully outlined and highlighted the care and support required by the individuals, such as health and personal care needs. This enables the staff to support the residents and provide positive outcomes for them. Signed contracts and agreements, containing fees and charges for the service, were seen for two residents. Residents are invited to visit the service prior to admission to meet the staff and the other people who live there. A resident spoken with confirmed she had been to the home on several occasions prior to admission and met the staff, residents and stayed for tea. The manager confirmed she usually offers overnight stays but the resident was very anxious to move in. The residents spoken with provided positive comments on the home. I love it here its lovely. Two residents were at home during the visit and both were observed to be relaxed, comfortable and interacted well with staff. The two other residents attend day care provision five days a week. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are assisted to make decisions about their lives and participate in all aspects of life in the home. EVIDENCE: The AQAA reported the service constantly promotes residents’ choice and encourages them to be involved. Policies in place encourage them to take responsible risks to enable them to develop and maintain personal relationships. Two care files viewed showed details on the residents’ care needs. These included information on personal profiles, pen portraits, all about me, health care and medication needs. A person centred approach is in place to enable positive outcomes to be provided for residents. Residents’ strengths, short and long term needs are identified in their plan of care. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 12 The care plans are drawn up with the involvement residents who sign to agree their care. Activity plans seen showed how they access the community and interests. The care plan is broken down into individual elements, such as health, communication, culture and religion. Care plans are reviewed every two months by their key worker, who is an allocated carer who has full involvement with the resident and appreciates their racial/cultural beliefs. Care plans identify individual need, the action to be taken by staff and the outcome to be achieved. The key-worker completes a monthly summary report at the end of each month. It is an informative report and provides a general summary about the resident’s general health, activity/participation and any other significant developments. Staff spoken with said they are very involved with the recording of care files and review them with residents involvement. Staff commented: We know where everything is, as Ange keeps the records organised. Listen to me records seen are collated by staff in consultation with the residents and detail their personal likes, dislikes, family and How to support me when I am sad or happy. This enables the staff to be aware of the emotional needs of the residents. Residents are involved daily in decision making by choosing what to do for the day and what to wear. Meals are chosen by the residents during weekly resident meetings to plan menus. Alternatives are available if they wish to have something else. This was observed during the day one resident didn’t wish to have chicken and an alternative was given. Weekly residents’ meetings take place to discuss activities, holidays, meals and daily routines. Staff often spend 1:1 time with the residents to discuss personal issues and to provide emotional support when needed. A resident spoken with confirmed this and said, The staff are always there to listen and have a chat if I need to. The staff manage residents’ personal allowances and records are maintained of all transactions and receipts obtained. Policies and procedures are in place for finances to help protect the residents. Residents participate in all aspects of the home and are involved in daily tasks. Routines are flexible to meet residents needs and lifestyles. This was observed throughout the day as residents went to shops, watched TV or went to their rooms for a rest. Privacy was observed to be maintained at all times by the staff. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 13 Risk assessments are in place to enable residents to lead as independent lifestyles as possible, taking responsible risks. These are reviewed every two months or before if needs change. Behaviour plans are in place for residents to demonstrate triggers for staff to look for, actions to be taken and preventative measures. There is a missing person policy and residents have individual risk assessments showing what action must be taken when there is unexplained absence of a resident. Residents are provided information about their safety and measures are taken to minimise risks to enable residents to engage in activities of their choice. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are well supported to access community facilities and to maintain relationships with family and friends, which promotes their emotional wellbeing. EVIDENCE: Two of the residents attend a day centre Monday to Friday, where they participate in a variety of activities. Where residents do not attend a day centre, activities are provided, such as: baking, pub lunches, bowling and trips to places of interests. An activity budget is available weekly and the manager confirmed that there is plenty of money for food and activities. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 15 The residents are responsible for household tasks, such as: food preparation and cleaning of their bedroom with the support from the staff. Residents were observed to go shopping, draw, help prepare meals and watch TV during the visit. Each resident has a separate daily diary sheet where the key worker notes down daily activities each resident has participated in. The key-worker’s monthly report also gives an indication of the activities planned and executed through the month. All the residents went on a holiday to Blackpool in September 2007. Discussion with one resident took place who commented: I enjoyed it very much but the caravan could have been bigger. The staff members support the residents to develop relationships with their family and friends through telephone conversations and weekly visits. There is an unrestricted visiting policy. Residents are able to choose where to see their visitors, either in the sitting room or in their bedroom. Menus are planned two weekly at the residents’ meetings but are flexible if residents decide to have a change or go out. Alternatives are provided should the residents wish to have something else. Healthy options are available and one resident is having nutritional assessment to encourage healthy eating. Lunch was served in pleasant, unhurried way. Staff and residents were observed to interact positively and a pleasant, relaxed atmosphere was present at all times. Staff have worked with the residents for some years and expressed their enjoyment and satisfaction of their job. Each resident has her own room with a key and lockable facility. Staff do not enter without knocking. Residents were seen to have private time and staff respected their wishes. Observation of residents showed that they choose whether to be on their own or with others in the communal areas. The service is situated close to shops, leisure centre, library, pubs and churches, etc., which residents access independently or are accompanied by staff. The residents have access to all parts of the home. Staff spoken with said they felt that the residents were offered a good range of activities. One resident was spoken with who said that she is happy here and likes her room. She also said that she goes out regularly and feels safe. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 16 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): Standards 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The arrangements for monitoring the residents’ health are good and this helps ensure that they are receiving the appropriate care and support. EVIDENCE: Care plans seen identify when personal care and support is required and this can sometimes be 1:1. These hours are calculated by manager so correct fees can be charged from placing authorities. Routines are flexible, however two residents attend day care five days a week and need to be up early for transport. All health care needs, appointments and visits are recorded daily. Care plans are reviewed two monthly to assess changing needs. All visits to health care professionals are recorded and showed optician, GP, dentist and breast screening appointments. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 17 Key workers complete a monthly summary on health care, activities and residents’ well being. Health passports are in place and are transportable to provide information for all appointments and visits to health care professionals. These contain all health care information and how I communicate, diet, food likes and dislikes. The manager confirmed this works well. The manager has recently been on a course into Anticipatory care calendar for people with a learning disability and is to incorporate this into the residents’ care and support plans. This will enable the staff to monitor closely all health care needs of the residents and note any changes in areas such as pain, urine, bowels, behaviour and any needs relating the resident’s personal health. Changes can then be recorded, carefully monitored and reviewed by health care professionals. These are scored in amber for urgent issues and the action taken, i.e., GP contacted, recorded. Residents confirmed they attend appointments and are supported by staff at all times. Medication policies and procedures are in place for all administrations. None of the residents self medicate. Each resident has signed a consent form indicating that they agree to staff members administering their medication for them. All staff are trained in medication and records seen and staff spoken with confirmed this. Medication is securely stored. All medication received and returns recorded and checked by staff. MAR (medication administration records) are completed for all administered drugs. Controlled drugs records are made and all accounted for by one member of staff and checked frequently by the manager. Staff are unable to countersign, as there is often only one staff on duty per shift. An improved system of recording controlled drugs was recommended and agreed by the manager during the visit. These are presently recorded on sheets and not in a numbered paged book. Behaviour management details of residents are on their medication file for reference for staff and other information on residents’ care needs. The manager conducts monthly audits and records are made of staff competency in medication administration. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 18 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): Standards 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are good policies and procedures in place that help to protect residents, and enable them to raise concerns should they feel the need to. EVIDENCE: Complaints policies and procedures are in place and residents have information about how to complain in the service user guide guide, statement of purpose and welcome booklet in an easy read format. A copy of this is kept in each resident’s file. Residents spoken with confirmed their understanding of how to make a complaint should they wish and said I would tell staff or speak to Ange. No complaints or safeguarding issues had been recorded at the time of the visit. All staff recruited following correct procedures and Criminal Record Bureau checks (CRB) and two written references. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 19 Policies and procedures are in place to protect residents from financial abuse. Records are kept of all incoming money and payments from residents’ accounts and a secure place is available for the storage of their valuables and monies. Personal finance records of the residents who were case tracked were checked, and found to be satisfactory. The home has a policy and procedure in place with regard to the protection of vulnerable adults. Appropriate policies on whistle-blowing, equal opportunities and protection of vulnerable adults are in place and available to staff. All staff members have appropriate training on protection of vulnerable adults. Staff spoken with confirmed that they know what the procedures are and commented: I wouldn’t hesitate to report it. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 20 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): Standards 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The accommodation is maintained to a good standard that promotes a homely and safe environment for the residents. EVIDENCE: The accommodation was found to be very clean, well maintained and comfortable. Each resident has their own room with attractive décor, good furnishings, carpets, lockable doors and lockable drawer facility. The furnishings are domestic in style to promote a homely environment for residents. All parts of the premises are easily accessible to users. However, the service is not designed to accommodate wheelchair users. Personal items, such as CDs, TV, photos and ornaments are contained in each room for their personal use. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 21 Residents spoken with said they were very happy with rooms. My room is lovely. I come here when I want to have a rest in the afternoon. The manager has applied for some areas to be redecorated. The entrance hall is inviting and contains a visitors book and information. There is a communal lounge, which is comfortably furnished. The kitchen/diner was found to be clean and contains all equipment, such as a washer. The home laundry facility is sited away from the food preparation area and various policies and procedures are in place to prevent the spread of infection. All the residents share the bathroom. A small tidy garden with seating is available at the rear. No radiator covers were found throughout and it was recommended these be supplied/or risk assessments put in place to ensure residents’ safety. The manger confirmed risk assessments would be completed at the time of visit. A good maintenance programme is in place. The manager completes monthly reports for the company and highlights areas in need of repair. The manager said the company is good at responding to repairs, which are colour coded for priority work. Regular home audits are completed to assess repairs needed and action taken. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 22 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): Standards 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff members have the necessary skills and competence to meet the assessed needs of residents and are well supported through regular training and supervision by the registered manager. EVIDENCE: The staffing levels reflect the level of activity/needs of the residents. The staffing level is sometimes higher in the evenings and weekends, as residents engage in a range of activities where individual support from staff is required. Two staff files were checked, and found to be satisfactory. The training records of two staff members were also checked. All staff members receive training on mandatory topics, such as manual handling, to ensure that the residents are moved safely. Specialist training courses like epilepsy awareness, challenging behaviour and diabetes are also provided from time to time. All staff members are appropriately trained in protection of vulnerable people and administration of medication. Appropriate staff induction procedures are in place. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 23 A training matrix is in place to evidence training completed and certificates are evidenced in staff files. Over 50 of the staff are trained in at least National Vocational Qualifications (NVQ) Level 2 or above. All staff members are supervised every two months and daily informal supervision is provided when the staff need advice. Staff spoken with commented: I have worked at home for over four years and I am very happy. I Love it here and enjoy my work. Ange is very supportive. We get lots of training and its all up to date. I have just done an equality and diversity course which was great. Ange is not just a boss, she is a good friend. Residents spoke highly of the staff and their relationship with them. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 24 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): Standards 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed in the best interest of the residents. EVIDENCE: The manager qualified in NVQ Levels 2, 3 and 4 and has a Registered Manager’s Award. The manager is registered with the Commission to cover two sites and discussion with staff and the manager confirmed this is working well. There is always a senior on duty when the manager is covering the other site. Staff were very complimentary regarding the managers support and approach and commented She is always available if we need her. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 25 Viewing of systems and procedures showed that all records are up to date, organised and easy to access. Staff reported that they are able to access any information when the manager is not on duty at the site but she is always available for assistance if they need it. It was evident that the manager runs a good home in the interests of the residents who live there. It is their home (Manager). Residents are encouraged to have their say and annual surveys are completed, which the manager collates and takes any action needed to improve services. Weekly meetings held for residents for them to have their say on the service provided. Good audit systems are in place to ensure staff and residents’ safety. Daily checks are completed by staff on fire exits, fridge temperatures, medication, finances and food stores. This ensures that all records are up to date and residents are safe and cared for. The manager also completes monthly checks on these areas. Three monthly checks are completed by the manager on fire drills, meetings and staff sickness. Other six monthly and annual checks are completed to ensure all certificates for services, such as electricity and staff training, are up to date. A fire risk assessment is in place and fire records are up to date. Fire drills take place monthly and are recorded. A maintenance log of all repairs is maintained and daily checks of safety made by staff. All accidents and injuries are reported. These regular checks ensure the safety of the residents and staff. Policies and procedures are up to date and available to staff. The company conducts an annual review of all policies and procedures. Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 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 3 25 3 26 3 27 3 28 3 29 3 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 3 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 Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? New service 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. Standard Regulation Requirement Timescale for action Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 28 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 YA20 Good Practice Recommendations It is recommended that numbered, paged controlled drugs registers be used to ensure records are safely maintained. It is recommended good practice that countersignatures are obtained for all medications administered to ensure residents’ safety. Discussion with the manager and records seen confirmed that weekly audits are completed to ensure clear accounts are made and staff are competent in this area. The manager confirmed that countersignatures are difficult to obtain, as there is usually only one staff on duty per shift. It is recommended good practice that countersignatures are obtained for all medications administered to ensure residents safety. Discussion with the manager and records seen confirmed that weekly audits are completed to ensure clear accounts are made and staff are competent in this area. The manager confirmed that countersignatures are difficult to obtain, as there is usually only one staff on duty per shift. No radiator covers are in place in the accommodation. The manager agreed to conduct risk assessments for all areas to provide a safe environment for the people who live there. 2 YA20 3 YA24 Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection NW Area Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Balfour Road (31) DS0000071746.V369808.R01.S.doc Version 5.2 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. 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