Inspection on 25/07/06 for 126 Castle Lane

This inspection was carried out on 25th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

126 Castle Lane 11/01/06

126 Castle Lane 16/08/05

126 Castle Lane 15/02/05

126 Castle Lane 28/09/04

126 Castle Lane 23/03/04

126 Castle Lane 12/12/02

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 18-65 126 Castle Lane 126 Castle Lane Olton Solihull West Midlands B92 8RW Lead Inspector Joe O`Connor Unannounced Key Inspection 25th July 2006 10:10 126 Castle Lane DS0000043658.V298230.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 126 Castle Lane DS0000043658.V298230.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. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 126 Castle Lane Address 126 Castle Lane Olton Solihull West Midlands B92 8RW 0121 743 1110 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) Robinia Care West Midlands Limited Ms Christine Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Should the standard of the care within the home deteriorate due to the manager being responsible for two other homes, then an individual manager will be required. 11th January 2006 Date of last inspection Brief Description of the Service: 126 Castle Lane is located along a quiet residential road in the Olton area of Solihull. The service is close to local bus routes for Solihull and Birmingham. It is within reasonable walking distance to local amenities. It is currently registered to provide accommodation and support for three adults with a learning disability. The current group of service users are three women. The premises consist of three single bedrooms one of which are located on the ground floor as part of a garage conversion and has a wash hand basin. There is a separate lounge and dining room with a fully equipped kitchen. On the first floor is a bathroom with a bath, shower cubicle, toilet, and wash hand basin. There is also an office that is used as a sleep in room. There is a toilet on the ground floor. To the rear of the property is a large well maintained mainly lawned garden and there is limited roadside parking. The building is not accessible for people with mobility difficulties including wheelchair users. The weekly fee for this home is a round £1,172 per week Additional charges includes those for hairdressing, chiropody and toiletries. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over a day and the fieldwork was unannounced. Two people who live in the home were present one of who was able to provide some comments about life in the home. The Inspector also spoke to two members of staff and the Registered Manager. Comments were received from two staff who had completed a CSCI survey form. A partial tour of the premises was completed. Care records including care plans, risk assessments and daily reports were also sampled. Other records examined included staff recruitment and training and those for health and safety. Additional information was also examined from the pre –inspection questionnaire that is sent out to the home before the fieldwork visit along with a history of the home including any significant events. Some observations of care practices were also undertaken. To see how the home has performed since the last inspection then the report should be read with the unannounced inspection report 11 January 2006. What the service does well: The people live in a home where its external features are similar in design to that of neighbouring properties and it that its purpose as a care home isn’t known. It generally provides a clean, homely environment that is very much part of the local community. Two people were present during this inspection and one person expressed her delight in choosing her favourite summer dress for the day. She also spoke of about looking forward to her birthday and was going to invite some of her friends from the other homes run by the Robinia group in the Solihull area. One person who was unable to speak was being supported by staff to use various soft materials to encourage her to communicate. The atmosphere was relaxed and people were seen to be dressed in smart, suitable clothing just right for the climate of the day, which was hot and sunny. Staff were observed to provide friendly and professional support. There is a good relationship between them. The people who live in the home are female and white and they get appropriate support and care from a mainly white female staff team. The staff are given opportunities to have a range of training courses including specialist courses such as understanding autism and managing medication management. The management of medication was found to be very good with no errors seen on the Medicines Administration Records. It was good to see that the manager and staff had supported one of the people to go on holiday with her boyfriend, which at the time of this visit was going very well. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 126 Castle Lane DS0000043658.V298230.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 126 Castle Lane DS0000043658.V298230.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, 3 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Improvements are being made to meet the needs of service users with an increase in staffing levels. Improvements are needed with the information currently provided for the service users about the home and should be available in an accessible format. Standard 2 not assessed. EVIDENCE: At the time of this inspection there were two service users who were present. One who has non verbal communication needs was not at her day centre as a staff member commented the service user was recovering from an eye infection. There was evidence confirming when she had been to the Eye Hospital for appointment and the medication used to treat the infection. The service user was sorting through her multi sensory soft objects. Another service user was in her bedroom listening to music and later spoke about how much she was looking forward to her birthday and wanted to invite other people from the other Solihull Robinia homes. Observations at the time of this visit indicated that the service users were being supported appropriately with their personal care and were dressed in clothing that was well co-ordinated and suitable for the climate of the day. The atmosphere during the visit was relaxed and friendly. Surveys for service users, relatives and staff were given to the manager of which two were received from staff that are included in the Staffing section of 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 9 this report. The service has had no new admissions since the last inspection although two service users files sampled found they had recently been assessed by social workers as part of a financial review. Copies of the assessment tools were on file including new care plans drawn up by the social workers. The manager stated that the social workers were satisfied the service was meeting the needs of the current group of service users and that all three still met the criteria for residential care. Each service user had a copy of the criteria banding determined by the social worker stating that their assessed needs were critical. At the time of this inspection improvements were being made with the recruitment of additional staff for the evenings. A senior member of the staff team was inducting two new staff. This will ensure the safety of the service users and give wider opportunities to go out during the evenings. There service does have a statement of purpose and a service user guide. When looking through the service user guide it was noted that this document needed reviewing and the information made more accessible which the manager acknowledged needed addressing. There were no new admissions to the service since the previous inspection. 126 Castle Lane DS0000043658.V298230.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, 8, 9 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. How service users needs should be addressed are set out in care plans that are in a suitable accessible format. Some improvements are needed in ensuring service users meetings evidence service users wishes have been addressed to their satisfaction. Individual risks are identified and managed appropriately in the home and in the community for the safety of service users. EVIDENCE: Each service user has a care plan that is in a large print/symbol format that has illustrations. These include information about individual’s daily routines including the time they got up and go to bed. One care plan stated that the service user must drink de-caffeinated tea to help her with her anxiety. Another referred to how her hair should be treated. The also referred to their preferences with regard having a bath or shower. It was noted that the illustrations and photos used were not relevant to the service users circumstances such as a photograph of people involved in their lives including staff and relatives. This had been raised with the manager at the previous inspection. There are also written care plans, which have aims and objectives with staff completing a monthly evaluation of these objectives. However, one 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 11 seen used a reference such as “ongoing” without indicating whether there were any changes to the individual’s aims and objectives. Overall though the care plans were reviewed since the last inspection and monthly reports are completed covering any appointments or significant events involving the service user. Each service user has an information sheet that includes details of their next of kin, date of birth and their religion. Two of service users are Roman Catholic although from discussion with the manager they do not choose to go to Mass. The service users have a meeting every Sunday where they have the opportunity to choose the menu for the week and what activities they would like to do. One service user who is unable to communicate verbally has a menu picture book where staff encourages her to choose what she would like to eat. Some improvements were needed with the minutes of the meetings as one of the service users during one meeting requested to go swimming. There was no evidence indicating whether the service user had been swimming following the meeting. The minutes for these meetings must include a plan of action of who will address any requests made by the service users with a progress report to confirm these had been addressed. A sample of two service users’ daily diaries referred to where service users had chosen what to wear. One spoke about the dress she enjoyed wearing at the time of this visit and said she chose it herself because she liked it. Each service user has a risk assessment, which had been reviewed since the last inspection. The risk assessments also included how service users should be supported in the community. Another referred to how a service user should be made safe when having a bath. There were behavioural guidelines in place for a service user who at can become agitated and upset. These were drawn up by a Clinical Psychologist to enable staff to provide consistency and support should any incident occur. 126 Castle Lane DS0000043658.V298230.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, 14, 15, 16, 17 Quality outcome in this area is adequate. This outcome has been based on available evidence including a visit to the service. Service users would benefit in having more variety of activities than what is being currently offered and provided. Service users are offered a variety of meals but what is actually consumed is repetitive during the week. EVIDENCE: One of the service users attends a day service by the Local authority during the week. The pre-inspection questionnaire states that the activities available to service users includes horse riding, multi sensory centre called Relaxaway college sessions and shopping. An examination of the service user’s daily diaries indicated occasions when these activities had occurred. The service users also go to the cinema and have on occasions gone out for meals out to pubs and McDonalds’ and for walks in the locality. At the time of this inspection two service users went out for a drink at a local pub in Olton. One of the service users said she enjoyed going out to the Relaxaway centre because she liked to lie on the massage table. She also said she was looking forward to going back to College in September where she was doing flower arranging. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 13 It was noted that due to the service being short of staff the frequency of these activities have been low. Discussion with the manager identified the need for a wider range of activities. The manager commented that the situation was likely to improve with the addition of new staff, which would give the service users wider choices of activities in the evening. A new Team Leader has been recruited whose expertise is in developing day services in a residential setting. Further examination of the daily records referred to how service users spent their leisure time including watching DVD’s, listening to music or being involved in board games. One service user who has non verbal communication has a variety of multi sensory objects. Two service users are of Irish origin had attended the St Patrick’s Day parade in March this year. Service users’ routines were known and respected and their daily records indicated where they had chosen not to participate in activities. There are records in place where staff record any domestic tasks completed by the service users including laundry, making drinks and cleaning their bedrooms. Staff interaction between the service users was positive and friendly. One of the service users has regular visits from two of her sisters and goes out with them at the weekend while another has been in a long term relationship with her boyfriend which the manager and staff have been very supportive. At the time of this inspection both were on holiday in Minehead and the manager was pleased that they were managing well and enjoying themselves. The service user had phoned the manager during this visit and said everything was fine and she was enjoying her herself. Another service user does not have any family contact although she has regular contact with an advocate from the Advocacy in Action group based in Solihull. An examination of the records for food eaten by the service users indicated that most of the meals eaten during the week tended to be repetitive. For example there were three days during the week where service users were consuming chips for lunch, tea or dinner. Discussion with the manager highlighted the need for staff to show more evidence they are encouraging healthy eating. The manager has developed the food menus in a photographic format to make choosing meals more accessible. 126 Castle Lane DS0000043658.V298230.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 outcome in this area is good. This judgement has been based available evidence including a visit to the service. Service users health and personal care is managed well promoting their good health. EVIDENCE: Two service users care records sampled indicated they were accessing community healthcare services such as their GP, Dentist, Optician and Chiropodist. There were records in place of these visits outlining any action to be taken. One of the service users was receiving specialist support from a Clinical Psychologist and Consultant Psychiatrist. One care plan sampled did need an amendment to say that one service user required their feet to be treated every three weeks otherwise there was information available regarding service users personal care requirements. There was evidence one service user had been consulted about attending a well woman clinic for breast cancer screening. Each person has a yearly health check, which is partly completed by a GP. It was noted one was due for an update, which the manager said she was currently addressing. Improvements had been made with the recording of service users’ weight, which was being completed every month. The service currently accommodates three white women and the care staff team are predominantly white female and therefore appropriate gender care is provided. An examination of two service users’ care records indicated where 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 15 they had support or completed personal care tasks such as having a shower, bath, dressing and undressing. Each service user has a manual handling assessment and these had been reviewed since the last inspection. There was evidence in the daily diaries that the service users were able to have a lie in. At the time of this inspection one of the service users said she had asked staff to have a lie in because she did not feel well during the night. Medication management was to an acceptable standard. An examination of the Medicines Administration Records found there were no gaps in recording with photocopies of prescriptions attached to the back of the MAR sheets. A written protocol is in place for the use rectal diazepam PRN. A detailed medication procedure was on display that was specific to the service. The supplying pharmacist had visited the service in May this year and identified three issues such as signing for when paracetamol has been given, date labelling cough linctus when opened and enter medication details when it is prescribed in the middle of the MAR sheet cycle. An examination of staff training records indicated that most of the staff had completed medication training. A visiting professional questionnaire had been completed by a Clinical Psychologist. The Psychologist said she thought the staff always show concern for the users and make ample effort to make her visits effective. They also demonstrate a high level of care towards the service users. 126 Castle Lane DS0000043658.V298230.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 outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users have access to an accessible complaints procedure, which is in an appropriate format. Service users interests are well protected with robust systems in place for the management of their personal allowances. EVIDENCE: Neither the CSCI nor the service has received any complaints since the previous inspection. Each service user has a copy of the complaints procedure including one that includes a photograph and illustrations of who service users can contact. It was also in a larger print format. A photograph of the Inspector was on display in the hallway. There are procedures available in the home with regard to the protection of vulnerable adults. There is a copy of the Multi Agency Guidelines by Birmingham Social Care & Health. An examination of staff training records found the majority of staff had training in adult protection. Since the last inspection the organisation is now working with a new training provider called Team Teach who provide accredited training in physical intervention. A newly recruited member of staff interviewed provided satisfactory responses to questions about dealing with poor practice and felt confident to report any concerns to the manager. Two service users’ personal monies were sampled and there was evidence seen to confirm these were being managed appropriately. There were receipts for personal expenditure including the reason for the purchase. Each service user has their money held individually. The service users also have a financial 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 17 profile, which provides information about their individual benefit entitlements. The monies are stored securely in a safe. There was recorded evidence seen that these are checked by staff at each handover. 126 Castle Lane DS0000043658.V298230.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 outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Improvements have been made to the premises but further work is needed to improve service users quality of life. EVIDENCE: Generally the premises was clean and tidy at the time of this visit. Information seen on the pre inspection questionnaire and when touring part of the premises found some improvements had been made. A new double shower and flooring had been installed. One of the bedrooms had been re-decorated. The dining room had been redecorated along with the hallway and the ceiling on the kitchen. New furniture was installed in the dining room. There were however, parts of the premises, which require further work. The décor in the main living room is tired and worn and would benefit in re-painting. The current colour scheme has been the same since the service was first opened in 1998. Much of the carpets in the living room, stairs and hallway was found to be dirty and in a poor condition. An armchair chiefly used by one of the service user’s was found to be in a worn condition. A representative of the organisation had also noted issues around the condition of the décor in a monthly report. The comments were seen in a Regulation 26 report completed following this inspection. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 19 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, 33, 34, 35 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Improvements are being made to increase staffing levels during the evenings giving service users more opportunities to participate in unplanned activities. Staff receives appropriate training enabling them to undertake their duties effectively. Recruitment practices ensures service users are supported by staff fit to undertake their duties effectively. EVIDENCE: An examination of the pre-inspection questionnaire indicated that out of seven care staff employed one was qualified to NVQ Level 2 and two had completed NVQ Level 3. One had recently commenced their NVQ level 3. An examination of three staff training records indicated three members of staff had completed a number of training modules towards the Learning Disability Award Framework (LDAF). Further examination of the training records found staff had completed training in mandatory topics such as manual handling, first aid, food hygiene and infection control. Staff had also completed training in autism, adult protection and safe handling of medication. The pre-inspection questionnaire stated that future training being planned was fire safety, managing service users’ finances and physical intervention. The manager stated that since the last inspection she was now in a position to provide additional staffing into the service. This will provide wider opportunities 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 20 for service users to have more activities during the evening and at the weekend. At the time of this inspection two new members of staff were being inducted and the manager also stated that a new Team Leader had been recruited. The manager acknowledged there had still been difficulties in maintaining appropriate levels of staff but with additional staff hours available the more dependent service users would have more opportunities for activities during the evenings. Two members of staff who had completed a CSCI survey form expressed their views that additional staff are needed especially during the evenings. The pre-inspection questionnaire stated that during the previous eight weeks an agency staff member had worked a total of seventy two hours. One member of staff has left the service since the previous inspection but so far the staff team has been stable. One completed staff recruitment record sampled for a new member of staff found all the required documentation was in place. These included job application form, interview assessment forms, contract, proof of identity, CRB and POVA First check, two references and a record of induction. There was also an equal opportunities monitoring form. Two members of staff spoken with had good knowledge about the service users in their care and the service users themselves were comfortable in the presence of staff. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 21 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): 37, 39, 41, 42 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. The service is well managed that promotes and protects service users interests with a manager who is committed to making improvements. EVIDENCE: The manager was present during this inspection and has worked hard in making improvements for the service users in her care. It was evident progress was being made in ensuring there were adequate levels of staff on duty. She also spoke positively of staff commitment towards the service users. One member of staff spoken with was positive that the newly recruited staff members would make a difference to the service users needs. Another member of staff who had recently been employed stated she was enjoying her work and found the manager and staff team to be approachable. A representative from the organisation visits the service every month although it was noted that a visit did not occur in June this year. Those reports sampled did not have detailed comments from service users and staff about the 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 22 management of the service. The manager followed up any issues identified during these visits with an action plan in place. Service users questionnaires were completed prior to this inspection. The format used for these questionnaires combined the use of illustrations and symbols. Satisfaction surveys had also been completed by relatives. When sampling these comments received were positive. Generally the records were up to date and locked in a secure facility. Health and safety records were sampled and these were satisfactory. There was documented evidence that the mains operated smoke detectors were tested every week. These and the fire extinguishers had been serviced following the last inspection. A fire drill and fire training had occurred prior to this inspection. The risk assessments for the prevention of fire and the premises had been reviewed since the last inspection. An examination of the accident book indicated two had occurred since the last inspection and these had been notified to the CSCI via Regulation 37. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 23 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 2 2 N/A 3 3 4 N/A 5 N/A INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 3 35 3 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 N/A LIFESTYLES Standard No Score 11 N/A 12 2 13 2 14 N/A 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 N/A 2 N/A 3 3 N/A 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(1) Requirement The Registered Person must ensure the Service User Guide is reviewed and drafted in a more accessible format for the service users. The Registered Person must ensure service users meeting minutes include action to be taken in addressing service users’ requests and an evaluation at the next meeting. The Registered Person must ensure it provides service users with a wider range of activities of their choice. The Registered Person must ensure staff evidence they are encouraging service users to eat more healthily. The Registered Person must ensure it provides the CSCI with timescales a plan of future refurbishment and decoration evidencing how the premises will be maintained to a safe and presentable standard. The Registered Person must ensure there are more details of comments made by service users in Regulation 26 Reports to DS0000043658.V298230.R01.S.doc Timescale for action 27/10/06 2. YA8 YA7 16(2)(m) (n) 27/10/06 3. YA13 YA12 YA17 16(2)(m) (n) 16(2)(1) Sch4 23(2)(b) 27/10/06 4. 27/10/06 5. YA24 27/10/06 6. YA39 26(1) 27/10/06 126 Castle Lane Version 5.2 Page 25 7. YA6 15(1) enable them to contribute about the management of the service. The Registered Person must include photographs of people involved in the service users’ lives in their personal care plans. 27/10/06 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 YA27 Good Practice Recommendations It is recommended that consideration be given to providing an en-suite shower room in the garage conversion in preparation for if the mobility of the service user occupying the room deteriorates to the point where she can no longer safely negotiate the stairs to get to the bathroom. Not assessed. 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 126 Castle Lane DS0000043658.V298230.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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