Inspection on 28/09/06 for 122 Carol Avenue

This inspection was carried out on 28th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

122 Carol Avenue 09/10/09

122 Carol Avenue 20/08/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Carol Avenue, 122 122 Carol Avenue Bromsgrove Worcestershire B61 8RH Lead Inspector Dianne Thompson Unannounced Inspection 28th September and 10 October 2006 14:30 th Carol Avenue, 122 DS0000066849.V313145.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 Carol Avenue, 122 DS0000066849.V313145.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. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carol Avenue, 122 Address 122 Carol Avenue Bromsgrove Worcestershire B61 8RH 01527 872692 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) www.dimensions-uk.org Dimensions (UK) Ltd Mr David Sampson Round Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03.03.06 Brief Description of the Service: 122 Carol Avenue is a traditional detached house in a residential setting providing a home for four people who have learning disabilities. The home includes a ground floor bedroom and bathroom facilities. Service users bedrooms are individually decorated and furnished with a lounge, dining room and kitchen shared by the household. There is easy access to public transport and the town centre. The house has its own vehicle for service users use. 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. This involves teaching skills and creating opportunities on behalf of individual service users. Service users are encouraged to participate in the running of the home and share in the general household activities within their capabilities. Dimensions (UK) Ltd is now the care provider for the service, having registered The with the Commission for Social Care Inspection on 1st April 2006. registered manager is Mr David Round. The current fee for the service range from £1547.00 per month. which are additional to the fee includes: • • • • • Personal toiletries and clothing Holidays Major extra outings Hairdressing Leisure and activities Charges Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Carol Avenue. This was the home’s first inspection since Dimensions (UK) Ltd registered as the care provider. The main purpose of this inspection was to assess the service provided against key National Minimum Standards. Service user and staff records were examined, and a tour of the building was also carried out. Information from the monthly visit reports by the provider’s representative was used in this report. Time was spent with service users, the registered manager and staff on duty. What the service does well: Carol Avenue is located in a residential area Bromsgrove that is not far from the town centre. The home provides for 4 people who have learning disabilities. The home provides information about the services they offer to help service users choose to live at Carol Avenue and whether the home will meet their needs. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. Personal and healthcare needs are included in care plans. These plans provide information to make sure that care is provided in ways that service users prefer. The home has a medication policy and procedure, which staff follow to make sure that all medication is given as advised and stored safely for the protection of service users and staff. Service users are protected by the home’s complaints procedure that is available in easy to understand format. The procedure gives information about how to complain, with information for staff to provide support as needed. Staff support service users to share their views and any concerns they may have. Carol Avenue offers service users a safe and comfortable home. The home is kept clean and makes sure that good hygiene and infection control is maintained for the benefit of service users. Adequate staffing levels are maintained and staff receive relevant training to help meet service users’ needs. The staff team understand their Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 6 responsibilities and are committed to their role. They work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that checks are made to ensure the safety of all service users. The home is managed in an open and positive way. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. 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. Carol Avenue, 122 DS0000066849.V313145.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 Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including visits to the service. Information is provided about the services offered at the home to help service users make an informed choice about whether they would like to live at Carol Avenue and whether the home will meet their needs. EVIDENCE: The home’s statement of purpose has been amended to provide up to date information about the home to help prospective service users decide if they wish to live at Carol Avenue. The registered manager said that copies of the revised Statement of Purpose and Service User Guide would be sent to families and relatives. All service users will receive copies of relevant information prior to moving into the home, and these will be offered in a suitable format, such as pictures and symbols. There are currently no vacancies at the home, but an admissions policy and procedure is in place should a vacancy arise. The home’s assessment process requires full information about prospective service users, their background, their needs, their likes and dislikes when they are referred for a placement. Information would be gathered from a range of sources including other relevant professionals, visits to previous homes or schools, and discussions with family members. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 9 Introductory visits and stays would be arranged at the home prior to admission. During the introduction to the home prospective service users are given a copy of the statement of purpose and service user guide. All service users have been given a copy of their new licence agreement from Dimensions. The new Statement of Purpose and Service User Guide contains copies of individual agreements with Dimensions to live at Carol Avenue. The information provides details about fees, services provided and acceptable behaviour in the home. The information is provided using pictures, and symbols to make information easily accessible. The registered manager was advised that where a statement is made about what is not acceptable, such as hitting, upsetting people or breaking things, there should be an explanation of the procedure to be followed should such events happen. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Care plans provide staff with information about service users assessed needs. They include risk assessments to say how risks are to be reduced and independence promoted. Service users are supported to make choices and decisions in their daily lives and routines, however care plans need to be updated and organised to make sure information is clear and accessible. EVIDENCE: Service user care plans contain information to make sure that care is provided in the way that service users prefer and in a way that encourages and maintains independence. Files for two service users were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Staff support service users who have lived at the home for many years and their care needs are well known to them. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 11 Of the two files examined it is clear that the recording system, the action and review process needs to be reviewed. Some information is duplicated, some information is out of date, and some information is difficult to read clearly due the alterations and the legibility of the writing. There are inconsistencies in the recording. For example, a photograph is included for one service user on a profile form, but not on the other file. A form for recording three new everyday exercises dated 2003 and 2004 is included in service user files, but no information has been recorded. This should be followed through where it has been agreed in the care plan process. Similarly, another service user is being assisted with communication. The intention is to identify words or sounds that are used to provide a list that says what these are likely to mean. This would be beneficial to both the service user and to staff, particularly new staff. The list has been partially completed, although started in November 2004. It was last reviewed as ‘ongoing’ in May 2005. The registered manager confirmed the records would be developed with the work that is planned. This needs to be time limited and must take priority. A person centred care plan (PCP) approach is being developed and the careplanning format shows service users will be appropriately involved in planning and reviewing their own care and will be supported to express their wishes and goals. A Path map has been completed for the home and for the service that is being provided. The Path map process has given staff knowledge and experience to support service users in completing their PCP’s. Staff said they found this experience very beneficial. The training and completion of the home Path gave them an opportunity to explore, share ideas and take responsibility for specific areas of work. Individual path days for service users are being planned. My life books are being completed. One example that has been started was seen during the inspection visit. The manager was advised that the pages should be typed, as handwritten pages are not easy to read. Also, using symbols and pictures will make information more accessible to service users. Each service user is allocated a key worker to oversee their care. Risk assessments have been completed and are evident in service users files. In the files examined it was evident that risk assessment reviews were completed in February 2006. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Service users receive help and encouragement to lead active and interesting lives and are supported to access facilities within the wider community. They are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of all service users. EVIDENCE: The home provides a wide range of activities for service users, both in-house and within the local community. An outings record sheet is held on service users files and some activity information is also recorded in care records. There are gaps in the recording of activities and insufficient evidence to show that activities are taking place on a regular basis. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 13 Service users and staff said that community activities include shopping, visits to the local garden centre, going for walks or a ride out in the home’s vehicle, and attending Padstone Day centre. Service users told of the visits they have made to places such as Cadbury World, a barge trip, and attending a football match. Another service user said they had been to see an Abba concert. One service user is a member of a people’s forum and attends with family members in Kidderminster. Activities within the home include watching TV and video’s, listening to music, involvement in daily household routines, e.g., laundry and cleaning. The home has an activity checklist for planning regular tasks such as pet care and tidying rooms. Service users happily discuss what they like to do and on the evening of the inspection visit a choice was made to watch Coronation Street on the television. Two service users also planned to prepare their lunchboxes for the following day. The home supports service users to maintain regular contact with their friends and family. Service users said they visit their friends from Millfields Day Centre and see their family regularly. The home provides a varied and balanced menu. The meal being prepared during the inspection visit was fish with mashed potatoes, peas and sauce. The opportunity for extra helpings was offered during the meal and a choice of desert such as fruit or yogurt was available. Staff and service users sat around the kitchen table for their meal, in a relaxed and unhurried manner. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to the service. Personal and healthcare needs are identified in care plans. The plans provide information about the care and support needed by all service users in a way that takes into account their preferences. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide information about their physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. The care plans will benefit from the planned development, which must be completed as a priority to make sure consistency of care is provided and maintained. Service users and the home are supported by medical services, which includes GP’s, community learning disability team, and dietician. Time was spent with Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 15 the registered manager discussing specific health concerns for some service users. Alternative options should be explored to improve the quality of life for individual service users and the people they live with. For example, where a concern is identified which means that access to services is restricted, support should be sought to find ways to address this. Arrangements are in place for preventative health services, e.g. dental checks and annual health screening, with evidence to show appointments and medical check-ups are taking place for all service users. Weight charts are evident, although there are gaps in the recording. These forms advise that monthly weight checks should be recorded. Health Action Plans are to be completed now that all staff have completed the training. Staff on duty and the registered manager said that all personal care is given in private to promote dignity for all service users. Conversations between service users and staff to decide who would provide the support they would need for their evening bath or shower showed that service users are able to express a preference and a choice of times, which was respected. The home has a medication policy and procedure in place. Medication is stored in a locked medication cabinet. All medication should be stored in individually labelled containers for each service user. Administration records were checked and show that prescribed medication is being administered, as required. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Service users are protected by the home’s complaints procedure that is available in easy to understand information about how to complain, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: During the inspection visit staff were observed engaging with service users in a supportive and respectful way. The home’s complaints procedure is available in widget signs and symbols for service users. The complaints log was examined and there are no records of complaints made to the home or to the CSCI since the previous inspection. The home has relevant policies and procedures to ensure service users’ protection. These policies and procedures advise and guide staff in protecting service users. Service users are now supported to retain their own finance in their rooms with a support plan available in the office to advise staff. The manager stated that Dimensions had completed a financial audit the day before the inspection visit. The manager said that the audit had been satisfactory. Service Users said they are able to talk to staff or the manager if they are unhappy or have any worries. All staff are involved in regular ongoing discussion and awareness about abuse issues. Dimensions recently sent out a letter to all staff regarding abuse that had been reported in the press relating Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 17 to NHS Homes. The letter also directed managers to ensure that discussions about abuse policy and guidelines take place in supervision and in staff meetings. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the service. Carol Avenue provides accommodation for service users that meets their needs and offers a safe, spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: Carol Avenue is a purpose built bungalow, with a large lounge and dining room, five bedrooms, one bathroom with toilet, one shower room, a separate toilet, laundry, office and fully fitted kitchen. There is an enclosed rear garden and small front garden. A tour of the home was completed. The home has a pleasant, relaxed and welcoming atmosphere. It is decorated and furnished in a homely way with flower arrangements on the tables. Photographs of service users are suitably displayed on the walls in the lounge. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 19 Service users said they are able to choose their furniture and the colours they want in their bedrooms when they are decorated. All bedrooms have been personalised by the occupants. The premises are clean and tidy. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. All cleaning materials are stored in locked cupboards in the laundry room. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. Adequate staffing levels are being maintained and staff receive relevant training to help them meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The registered manager said that staffing levels have increased since the last inspection. The manager also said that the change over to Dimensions (the new care provider) has been relatively smooth, and that the service users and staff team have coped very well. Staff complete the mandatory health & safety training such as fire safety, first aid, food hygiene, moving & handling and infection control. Other training Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 21 courses include communication, safe handling of medicines, abuse, working with people we support and managing challenging behaviour. Staff said that the recent Path training day was effective as a team building exercise, particularly with Dimensions as their new employer and care provider. The manager confirmed that there is a staff vacancy of 39 hours at the moment. Interviews are scheduled for end of this month. The home has experienced staffing difficulties for a number of months, with one person on long-term sick leave, and another member of staff on a three-month period of sickness absence. Additionally staff training is being completed which also means there have been additional shifts to cover. The home has bank staff it is able to call on, where all members of the bank staff are familiar to the home and the service users. A sample of staff records was examined. The manager confirmed that all prospective staff complete an appropriate application form and that references are obtained including one from their most recent employer. An enhanced CRB and POVA check is undertaken before their appointment is confirmed. From the staff files seen there is evidence that demonstrates that all checks have been completed and proof of identity has been obtained, such as photographs and copies of birth certificates. All staff are required to work a probationary period at the home and to complete the LDAF Induction Course. Staff meetings and supervisions have not been conducted regularly due to the staffing difficulties. The registered manager aims to improve this situation as soon as recruitment has been completed and additional staff have been employed. Carol Avenue, 122 DS0000066849.V313145.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to the service. The home is managed with an open and positive approach. Dimensions monitor the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager, David Round is a registered nurse (RNLD) and an NVQ Assessor. David has undertaken a range of relevant training courses that includes Our Approach (including quality outcomes), Our Purpose (including listening and enabling), Equality and Diversity, and Fire Training for Managers course. David is working to complete the NVQ Care Management Award, although this has been delayed through a change of assessor at the college. Staff confirmed that the manager is approachable and supportive. In respect of management support from the provider, Dimensions has Training and Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 23 Human Resource Officers who are available to advise and support the home. Service manager meetings are held monthly and the manager confirmed that he and the home are being supported. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how the home is being run. These visits include interviews with staff and service users and also include an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. This report will include service users, stakeholders and interested parties views on the service provision. Records show that monthly checks of the fire safety system & equipment, water temperature & storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health & safety training topics. Generic risk assessments are in place that includes the home’s vehicle. The home now has a computer installed in the office. The registered manager has completed the home’s fire risk assessment, and fire drills are being fully recorded when completed. Annual fire training was completed May 06 and meets the requirements of the previous inspection. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 24 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 3 4 3 5 3 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 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X X 3 X Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) (2) Requirement Timescale for action 06/12/06 2. 3. YA6 YA14 15 (1) (2) 16 (m) (n) 4. YA19 12 1(a) (b) The service users care plans must show how the service users needs in respect of their health and welfare are to be met. The care plans must be reviewed 06/12/06 regularly, they must be legible, accessible and kept up to date. The home must make sure that 06/12/06 all activities, in or out of the home are recorded, so that an accurate record of service users’ lifestyles is available. (Previous recommendation not met) The registered manager must 06/12/06 ensure that proper provision for the health and welfare of service users; and where appropriate treatment, education and supervision of service users is provided. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard YA5 Good Practice Recommendations Where a statement is made about what is not acceptable, for example, hitting or upsetting people, there should be an explanation of the procedure to be followed should such events happen. The registered manager should make sure that where monitoring charts are in place, that recording and monitoring is completed. All medication should be stored in separate, individually labelled containers for each service user. 2. 3. YA19 YA20 Carol Avenue, 122 DS0000066849.V313145.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Carol Avenue, 122 DS0000066849.V313145.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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