Inspection on 17/09/08 for Greenwood

This is the latest available inspection report for this service, carried out on 17th September 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 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 05/12/2008.

CARE HOME ADULTS 18-65 Greenwood 284 Harden Road Leamore Walsall West Midlands WS3 1RQ Lead Inspector Joanna Wooller Key Unannounced Inspection 17th September 2008 09:00 Greenwood DS0000071731.V371976.R02.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 Greenwood DS0000071731.V371976.R02.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. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenwood Address 284 Harden Road Leamore Walsall West Midlands WS3 1RQ 01922 864 616 01922 864 616 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) Greenwood Residential Care Home Limited Mrs Margaret Hanson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Greenwood DS0000071731.V371976.R02.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: 2. Learning Disabilities (LD) 5 The maximum number of service users to be accommodated is 5 Date of last inspection Brief Description of the Service: Greenwood is a small care home situated in Harden Road in Bloxwich. It offers accommodation with personal care to five service users with learning disabilities. All the people who use the service have their own single rooms, four of which have an en-suite facility. The main building is entirely occupied by the people who use the service, the owners have recently moved to their own accommodation within close proximity of the care home. The registered provider, Mrs Maggie Hanson has been operating this service since August 2001, she is also the manager. The fees are reviewed annually and people who use the service are notified one month in advance of the changes. The only additional charges to people using the service are for hairdressing, toiletries, chiropody and some leisure activities and associated transport costs. This is clearly laid out in the terms and conditions. Fees for Greenwood as of 1st April 2008 range from £714.10 to1, 387.94 per week. The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Greenwood DS0000071731.V371976.R02.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 that that people who use this service experience good quality outcomes. This unannounced inspection took place on Wednesday 17th September 2008 by the lead inspector. The Manager was available and she participated in the inspection process. The inspection included the following elements; A walk around the building, Observation and inspection of records relating to provision of care, Discussions with people, who use the service on return from day care, Case tracking whereby we select two people who use the service, chat to them and look at their care plans and lifestyle in the home. Discussions with the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, training, recruitment and health & safety. All assistance was given to gain the evidence required for the report. Commission For Social Care Inspection had dealt with no complaints since the last inspection. People who use the service were very content in the home; they appeared relaxed and very much at home. Communication with the people who use the service was limited however all the people were happy to meet the inspector and they talked about their hobbies and the days events. The Quality Assurance system in place evidenced that the relatives and multi disciplinary team were very impressed with the service offered at the home. The home manager sent us their annual quality assurance assessment (AQAA) when we asked for it. This document was completed to a good standard and gave us all the information we asked for. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were made at this visit. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 7 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. Greenwood DS0000071731.V371976.R02.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 Greenwood DS0000071731.V371976.R02.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): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service have their individual needs assessed. EVIDENCE: There have been no new admissions to the home since May 2005, but there are policies and procedures in place should there be a vacancy. The home has a Statement of Purpose and a Service Users’ Guide and these were available and the people who use the service are aware of their location in the home. The services Annual Quality Assurance Assessment tells us “We arrange visits to service user in their own homes, so that we can do a full assessment of their needs, lifestyle, culture, and diet. We provide them with a service users guide in a format that they can understand, and also explain to them about the rooms and layout of the home. We provide their families with a statement of purpose for them to read, also we arrange for them to visit us for a meal if they so wish. After gathering all information for the assessment including social services information we will re visit them and ask if they would like to stay with us for a weekend at the home and meet everyone who’s lives there Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 10 and all our staff. We will pass the full assessment and costing to the social services to go to panel, But this will only be done if the home feels we can meet all the requirements of the proposed service user, If we discover after doing the assessment on the proposed service user that we feel that we cannot provide the care we will decline the proposed service user, But if they move in to the home we will do a three month settling period.” Internal Quality Assurance surveys confirmed that information about the home is shared, and that people who live at the home are kept up to date with important issues. Employees and other health professionals were included in this. Full assessments were completed for everyone before they moved into Greenwood, which is the basis of the care plan formation on admission. All the people using the service had been referred by Social Services and a proper assessment was carried out prior to their admission. Annual reviews take place for five of the people and one other person is reviewed more frequently at present. There is a risk assessment in place for each individual, based on his or her specific needs and risks. The key worker updated these weekly. It was evident from talking to the provider and the people who use the service that the individuals needs and interests had been taken into account in care planning. Greenwood DS0000071731.V371976.R02.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 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service have their individual needs reflected in their individual plan. The people who use the service make decisions about their independent lifestyles with the assistance of the staff. EVIDENCE: Each person who uses the service has a daily report book in the form of a diary. Records include any events taken place during the day, food intake and appointments such doctor, dentist or hospital. Each person also has a • Health action plan – which is user friendly and kept up to date. This is taken with them to any medical appointment. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 12 • • • • Personal Care Plan and individual assessment Personal care assessment Risk Assessments Review sheet The Annual Quality Assurance Assessment tells us “Each service users care plan is reviewed on a regular basis by their key worker things can be added and removed as and when required, the key worker will speak to the service user concerning this there care plan is reviewed every six to twelve months with their social worker or facilitator. We have in place a health action plan for each service user, which is checked regularly, all appointments are kept and entered. We also contact person centred planning when a service user moves in to the home to have a plan put in to place which is done with the service user there family, and staff who work with them, this will cover their life style and what they wish to do in their leisure time.” The Registered Manager stated that the Person Centred Team reviews the plan annually. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. There is evidence of key worker support and encouragement to make sure that people who use the service are fully involved in the reviews of their care plans. Staff again said they are fully aware of the plans and follow them to guide their practice. An Advocacy Service is available locally however people living at Greenwood have not used this service recently. The Annual Quality Assurance Assessment tells us “We promote the rights to be different, freedom from discrimination, confidentiality, choice, dignity, effective communication, safety and security, advocacy, effective relationships, role boundaries, needs and recourses and challenging when others rights are not met. Through staff training we understand assumptions and oppressions such as those, which surround gender, race, age, sexuality, disability, class.” The people who use the service require assistance for all tasks. Each person is escorted outside the home by the key worked at all times. Choice is offered through out the day. Food, activities and outings are planned with agreement of the persons living in the home. One gentleman loves music and snooker; he goes to a local snooker hall or plays in the home. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service take part in appropriate activities within the local community. People who use the service maintain appropriate relationships with family and friends and their rights are respected. People who use the service are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: The Annual Quality Assurance Assessment tells us “Activities are arranged for each service user, in the home and also in the community, Day trips out are discussed with service users as to where they would wish to go, also holidays, service users attend day centres and we do shopping trips and community activities such as bowling snooker meals out and visiting different places such as, Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 14 Safari park, zoos, we try to help service users to maintain family links inside and outside of the home. We have a policy in place with regard to personal relationships. Service users rights are respected everyone has freedom to every part of the home, this excludes bedrooms, our routine with daily tasks is very flexible service users assist staff only if they choose to do so, meals are varied with each individuals diet catered for.” Activities are arranged usually at short notice depending on the people who use the service requests. Activities include meals out and walks in the park. Evening clubs are attended along with bowling, cinema trips and shopping. Summer Day trips to Sea Life Centre, Hatton Farm Village, Black Country Museum and Monkey World. This summer a holiday was declined by the people who use the service in preference of day trips out. Each person attends a local day care centre 5 days a week where they take part in varying activities such as karaoke, sensory room, pottery, arts and crafts. Unfortunately this service is under threat of closure although a new unit may be built in the near future. On the weekdays people who use the service take a packed lunch to the Day Centre. Evening meals at the home are now in form of a full hot meal. Menus are planned with the people using the service. One of the people who use the service usually go food shopping with staff from the home. Two of the service users are diabetic and their particular needs are catered for. Records showed the varied and nutritional meals that are provided and alternative meals where these have been chosen. Framed photographs were hung throughout the home showing events and outings. One lady chatted to us and showed us her painted nails. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are sympathetically supported and their physical and emotional health needs are met. People who presently use the service are supported with dealing with medication administration. EVIDENCE: The Annual Quality Assurance Assessment tells us “Every service user has a health action plan with their care plan, this contains how their health needs are to be met. There category of learning disability, communication, skin, toileting, mental health, health screening, sight, and dental care. We help service users where possible to manage their own medication. The staff train in medication and our policy and procedure for the staff to follow ensures medication is administered and stored safely for every ones protection. Staff supports all service users in a respectful way ensuring that each person’s dignity and self esteem is kept.” Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 16 There was evidence that all the people who use the service have a local GP service at a local practice. The chiropodist visits 6 weekly. Optician visit planned annually. Regular dentist visits are arranged. Regular checks and monitoring is being recorded in health action plans. This is good practice and demonstrates that health care and support can be provided more effectively if procedures are followed correctly. There is an improvement in the level of recording and information available in the care plans to advise and inform staff. The two diabetic people have regular checks with the doctor. None of the people using the service take charge of their own medication, although all have a lockable facility in their bedrooms if they wish to do so. Some people using the service have signed to say they consent to taking their prescribed medication. Not all people using the service are able to sign and in some cases a signature has been obtained from the next of kin. Medication is stored in a locked cupboard at an acceptable temperature. None of the people using the service are prescribed controlled drugs at present. A check was made of the medication and accompanying record sheets, which appeared to be satisfactory. A medication policy and procedure is in place and provide guidelines to follow should any medication error occur. The staff administering the medication is trained on a 14-week medicationtraining course. Each person returned from the day centre and put their coat away and put their slippers on, the manager made them all a cup of tea and they had a biscuit. Brian put his music on and planned a musical evening. The people were all very relaxed and interacted with each other well. It was evident that it was one big family – that mixed very well with each other and the staff. The staff chatted openly with the people who use the service and the atmosphere was very relaxed. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service feel their views are listened to and acted upon. People who use the service are protected from abuse, neglect and self-harm. EVIDENCE: The Annual Quality Assurance Assessment tells us “We have a complaints and suitable procedure in place to respond to any allegations for abuse and for managing complaints, the service users guide has them in picture format. All staff support service users to make a complaint, our survey shows that our service users and staff are aware of the complaints procedure. The adult protection procedure was reviewed and is in line with Walsall social services adult protection procedure, a copy is in the home for all to see, we do not use physical restraint, we have a whistle blowing policy and all staff are aware of their responsibilities with regard to the protection of vulnerable adults, Service users money is paid in to their bank accounts and service users go to draw money out for themselves. Monies receipts and records are kept of day to day spending monies and accompanying records of service users are independently checked by an accountant.” The people who use the service record had no complaints or concerns and no vulnerable adult strategy meetings had been required. The complaints procedure was in place Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 18 The home’s Adult Protection Procedure has been revised and is now in line with the Walsall Social Services Adult Protection Procedure, a copy of which is available in the home. It is the home’s policy that physical restraint is not used. The home also have a Whistle blowing Policy and the member of care staff on duty at the inspection was fully aware of her responsibilities with regard to the Protection of Vulnerable Adults. An independent Accountant on an annual basis checks monies and accompanying records of people using the service and records to verify this are kept in the home. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a homely, comfortable and safe environment. The home is clean and hygienic. EVIDENCE: The Annual Quality Assurance Assessment tells us “Greenwood is kept clean and re decorated when necessary which is always on going, service users bedrooms are decorated to their choice. The home is safe and comfortable and hygienic and free from odours. The garden has been made safely and accessible for service users to use, all radiators now have covers over them throughout the home in all areas, water temperatures are as they should be at 43 degrees service users bedrooms have been personalised by themselves with assistance from staff.” Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 20 The home is very comfortable and inviting. The people who use the service obviously feel very much at home. They each have their own bedrooms, which were personalised and tidy. The people who use the service are able go to their rooms as they wish and they are encouraged to be neat and tidy. The staff maintains excellent standards of cleanliness in the home and the home is well maintained to ensure the people who use the service are safe. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 21 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff that has been recruited using the homes recruitment policy and practices support the people who use the service. Staff that is appropriately trained meets the people who use the service needs. EVIDENCE: The evidence seen at the visit indicated that the home is adequately staffed. The registered Manager was present at the premises while all the people using the service were out at the local Day Centre. The Annual Quality Assurance Assessment tells us “We have a recruiting procedure which adheres to care standards each staff member has a training and development profile staff training is given to improve skills and knowledge of the needs of the service users, staff are supported and work together all staff are encouraged to raise any topic they wish to discuss at staff meetings. All staff do induction training and are put forward for nvq level 2 training as Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 22 soon as possible, mandatory training is ongoing, night wake staff are aware of their responsibilities while on duty for security of the building and welfare of the service users.” People using the service returned to the care home at 15.30hrs. The deputy care manager and a senior carer arrived on duty at 15.00hrs. Two carers are on duty during the day and one night carer on duty and either the Registered Manager or her Deputy is on-call and available in the event of emergency. The staff rotas were seen during the visit. The rota show the person who is on-call and available in the event of emergency. The staff were evidenced to have a great relationship with the people who use the service. The people using the service had a cup of tea once they had hung their coats up and put their slippers on. They planned to listen to music that evening whilst the roast dinner was being cooked. One of the people showed us his Compact Disks(CD’s)and put one on for us. The home has continued to use the training and development plan and staff files contained an individual training and development assessment and profile. Two staff files were examined in detail during the visit. All staff files contained all the required recruitment documentation, including a completed application form, two written references, Criminal Records Bureau (CRB) disclosure and a photograph of the staff member. Out of the present staff group of seven (including the Registered Manager) five hold an NVQ Level 2 or higher qualification. The Registered Manager stated that the remaining two carers will commence their NVQ training shortly at the local college. All the staff was enrolled on the fourteen-week dementia training course at present – which was Level 2 standard. All newly employed staff completes an Induction course. The Induction process was evidenced and this also includes new staff being supported by senior staff to familiarise themselves with the home, people who use the service and safety matters. Staff files seen evidenced that the staff had received formal supervision from the Registered Manager. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a well run home which is consistently under self-monitoring review by the manager. The health, safety and welfare of the people who use the service is promoted and protected. EVIDENCE: The Registered Manager has a wealth of experience in the delivery of care and an equally well-qualified Deputy Care Manager supports her. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 24 Both hold the Registered Manager’s Award, Mentoring Award and Assessors’ Award and they continue to take part in periodic training to update their skills. The manager distributes questionnaires to various stakeholders on an annual basis, seeking their views on the quality of services provided by Greenwood care home. The home had analysed the feedback received for the year 2007 and included the results briefly in the revised Statement of Purpose of the home in March 2008. The home had also submitted an Annual Quality Assurance Assessment to the Commission For Social Care Inspection and this fully reflected the feedback received. We promote all service users rights to quality of care safety and their health. We assess the home and the service we provide by a quality assurance survey every year, and amend our working practises as of the outcome of our survey, all annual checks are kept up to date, fire drills are done regularly, and fire lighting and alarm checks are done weekly. All incidents and accidents are reported to the appropriate agency, If need be a regulation 37 is sent to CSCI.” Annual Quality Assurance Assessment tells us “Equality and diversity for people using the service were seen to be promoted throughout the home within the assessments, care plans and activities. Equality for staff is promoted through the opportunities for training at all levels.” The home continues to keep records to show that health and safety of people who use the service is promoted and protected. There is Fire Risk Assessment in place. Evidence was again seen of regular maintenance of gas central heating system, emergency lights, the electrical system and electrical equipment. The water system is checked each year for legionella. All accidents, injuries, incidents of illness or communicable disease are recorded and reported to us. Records seen show that fire alarm system tests take place each week and that fire drills take place at least six monthly. Any new members of staff receive induction training in safe working practice topics and then full training is also provided. The staff training records showed that the staff had received their mandatory training in safe working practice topics. People using the service spoken with were very complimentary about the Registered Manager and staff in the home. They looked very happy and content. Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 25 Greenwood DS0000071731.V371976.R02.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 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 3 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 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 Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands 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 Greenwood DS0000071731.V371976.R02.S.doc Version 5.2 Page 29 - 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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