Inspection on 17/04/07 for 164 Coleshill Road

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

164 Coleshill Road 12/01/06

164 Coleshill Road 22/09/05

164 Coleshill Road 10/02/05

164 Coleshill Road 23/09/04

164 Coleshill Road 08/03/04

164 Coleshill Road 25/06/02

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

CARE HOME ADULTS 18-65 164 Coleshill Road 164 Coleshill Road Atherstone Warwickshire CV9 2AF Lead Inspector Yvette Delaney Key Unannounced Inspection 17th April 2007 09:00 164 Coleshill Road DS0000004312.V336354.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 164 Coleshill Road DS0000004312.V336354.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. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 164 Coleshill Road Address 164 Coleshill Road Atherstone Warwickshire CV9 2AF 01827 718528 F/P 01827 718528 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) Mrs Anne Fretwell Mrs Anne Fretwell Care Home 7 Category(ies) of Dementia (7) registration, with number of places 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: 164 Coleshill Road is a registered care home providing 24-hour personal care for up to seven adults with varying levels of dementia. The home is a twostorey house and accommodation for the seven residents is provided over two floors. Two of the single bedrooms are on the ground floor and two separate accessible bathrooms. A main lounge, which is extended by the addition of a conservatory, and a kitchen and dining room are provided on the ground floor. There is a stair lift to the first floor, where there are five single bedrooms, and a small office. There is sufficient garden space at the rear of the house. The rear garden is enclosed, and has been specially designed for the needs of people with dementia. A small parking area is available at the back of the home and onstreet parking is available outside the home. The home is in a residential area, a short walk away from Atherstone town centre. There is a bus stop just outside the home. In Atherstone, there are facilities such as post office, banks, shops, cafes, pubs etc. There is also a small post office a very short distance from the home. The owner of the home has advised that the current fees for resident accommodation varies between £600 and £900 per week. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place on a weekday, Tuesday 19 April 2007 between the hours of 11.00 am and 5.30 pm. The team leader for the home and the registered manager was present at the inspection. A visit was made to the sister home Merevale House to examine staff files at which the registered manager and the manager for Merevale House were present. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Before the inspection, questionnaires were sent to the home to be given to residents, relatives and GP’s to seek their independent views about the home. Completed questionnaires were received from five residents and three relatives. Comments received from relatives and residents express praise for the service that they receive and include: “…I can honestly say that he could not have better genuine care and attention in every way than here. I commend and congratulate the staff in every way.” The registered manager of the home completed and returned a pre-inspection questionnaire containing further information about the home as part of the inspection process. Some of the information contained within this document has been used in assessing actions taken by the home to meet the care standards. Two of the residents were ‘case tracked’. This involves establishing an individual’s experience of living in the care home by meeting or observing them, discussing their care with staff, looking at their care files, and focusing on outcomes. Records relating to resident care, staff training, recruitment and health and safety were examined. Relatives were not seen and spoken with during this inspection visit. Four staff, which includes the team leader and registered manager, were spoken with. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 6 The majority of residents in the home were able to make active contributions during the inspection visit. Further information to identify the outcomes for residents’ was also gained through observation of their interactions with staff and each other. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 164 Coleshill Road DS0000004312.V336354.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 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. People wishing to move into the home have their individual needs assessed ensuring that the home has the resources to meet their needs before admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been two new people admitted to the home since the last inspection. The pre admission documentation was examined and showed that it was sufficiently detailed to support staff in providing appropriate care to the two people admitted to the home. The homes own assessment documentation, personal profile documentation and rehabilitation plan have been completed for residents. Assessments completed by the home were also supported by assessments completed by social workers, consultant psychiatrists and Community Mental Health Nurses. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome group is good. Individuals are involved in decisions being made about their lives and play an active role in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two residents care files were examined at this inspection. These were detailed and informative. Individual residents needs were assessed and the level of support required discussed with each resident. Plans of care were written related to daily living such as personal care and support needs, daily living skills, leisure, interests and hobbies. Care plan documentation was dated and signed by care staff and the resident where appropriate. Residents spoken with said that they are involved in planning how their care needs will be met. Emphasis in the home is on providing person-centred care. Staff ensure that residents are able to make decisions about their day-to-day lives in the home. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 10 Risk assessments are completed these help people living in the home to live their lives safely and independently. Risk assessments and the management of risks are discussed and reviewed with residents. Individual risk assessments were seen and examined in resident’s care plans these were specific to individual requirements. Risk assessments examined include access to the community both in respect to mobility, access to various venues, involvement in domestic duties for example kitchen cleaning and shopping for the home. The care files examined showed the level of support required from staff by the residents followed through the case tracking process. Residents’ involvement in activities in the home and participation in community events are recorded in their care plan and picture album. Photographic life stories contain photographs, pictures and written information. The stories are updated to keep them live. A key worker reviews care plans monthly to ensure that they reflect residents’ current needs. Care plan documentation shows that residents are involved with the reviews and other representatives are invited as appropriate. Individual residents signed care plans and a contract with the home to say that they agree with specific conditions related to their care. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome group is excellent. Opportunities are available in the home to ensure that residents’ day-to-day living experience offers a positive and varied lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently provides a service for seven men aged between 49 and 73 years of age who have varying levels of independence. The plan of care for each person is for staff to encourage and support individuals to maintain their independence. The opportunity to support residents in taking part in social activities of their choice is encouraged. Group activities are offered and some residents had taken advantage of the good weather and gone to a local park for a picnic on the day of the inspection. One of the residents spoken to on their return said that they had enjoyed their day. Pictures were seen of other group activities, which had taken place these include bowling, meals out, a trip to Twycross zoo and holidays. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 12 Minutes of a resident’s meeting and discussion with staff and residents demonstrate the extent to which they are involved in planning their daily life in the home. Evening events take place in the home and people using the service were able to relate to an ‘Asian’ evening where a cook was invited to the home to cook an authentic Asian (Indian) meal and music of Asian origin was played. The contents of the minutes contained suggestions on meals, activities and entertainment individual residents would like to see. Minutes of a resident’s meeting and discussion with staff and residents demonstrate the extent to which residents are involved in planning their daily life in the home. The contents of the minutes showed that it was a proactive meeting. Discussion had taken place about meals, activities and entertainment individual residents would like to see. Annual holidays are planned and based on individual resident’s choice and capabilities resulting in different types of holidays being arranged. The opportunity to take a holiday in England is available to residents. Resident’s spoken with were able to confirm this approach to planning holidays and group activities. Relatives are also able to join their relative on holiday if they wish. Residents have attended day centres and colleges which encourages life long learning. Certificates were seen of courses attended these include computer related courses. The home supports these activities and encourages residents to attend. Discussions with resident’s evidence that family and friends are welcome to the home and that resident’s are supported to visit relatives. Two visitors were spoken with on the day of inspection. They were encouraged by the improvement they saw in their family member and commented that “…Looks so much better and has settled better at this home.” The visitors were able to take their relative to the shops for a walk. One of the visitors said that they visit weekly and find the staff easy to talk to and helpful. The visitors felt that the staff had taught them a lot about their family member and helped them to understand their condition. This had especially been important as their relative sometimes exaggerated conversations. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 13 Residents were able to confirm how staff respect their privacy and examples of staff knocking on bedroom doors before entering. Privacy linked to the level of risk when residents are using the bathroom has also been assessed. One of the residents followed through the case tracking process explained the support they received from staff when bathing, this explanation was also supported by the information in the care plan. Resident’s accompany staff to do the food shopping and assist with food preparation if they choose to and if safe to do so. Residents were able to give support in the kitchen at a level to meet their assessed needs. Some residents were able to wash up others made cups of tea or made small snacks. Residents said that they enjoyed their meals. A record of daily meal choices showed that residents are given individual choices. Records and conversations with care staff and residents show that a choice of meal is offered to residents daily. Residents also choose if they are going to have their main meal at lunchtime or in the evening. Residents had chosen to have their main meal in the evening on the day of inspection sandwiches were eaten at lunchtime. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome group is good. The health and personal care that people receive is based on their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were sufficiently detailed in providing staff with information on residents’ likes and dislikes and their preferences related to personal care. The owner/registered manager for the home has recently (2 weeks previously) introduced new care profile documentation, which staff are adapting to using. The care plans for two residents were examined and cross-referenced with all available files related to each resident. Care planning documentation was collectively informative. The care planning process is person centered. This ensures that planning a residents care focuses on positive outcomes for the individuals. Care plans identified the individual needs and wishes of residents and state how these should be met by care staff including, their personal care wishes and choices. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 15 For example a care plan related to mobility detailed the level of support a resident required from a member of staff when accessing the community and the need for a wheelchair for long journeys. Talking to residents confirmed that they are involved in planning how their care needs would be met with the support of care staff. A resident explained their need for assistance when taking a bath and was able to discuss their involvement in planning how much and what support was needed from staff. The content of care plans concentrate on promoting independence and involving residents in deciding how they spend their day-to-day lives in the home and community. Specialist healthcare advice regarding the management of residents has been sought through GP’s and community psychiatric and district nurses. Support services are accessed for the specific needs of individual residents as necessary. Where possible and with the support of social services and other professionals individual residents are assessed and helped to move back into the wider community. The team leader spoke about a resident who had recently been successfully rehabilitated into the community with the necessary support. Residents are helped to access appointments in the community this includes visits to the dentist and hospital. The owner spoke about plans to commence GP assessment and review clinics at the home, which would involve other professionals as appropriate. Policies and procedures are in place to support staff to administer medicines to residents safely. There were no residents considered able to retain and control their own medication. Medication administration records examined showed one omission, which was addressed. Medication received in the home and those returned to the chemist were recorded. Medicines were being stored securely. Family members made the following comments in their questionnaires on the care provided in the home: “I am very happy with the care my husband receives…” “Very satisfied with the overall care provided.” 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome group is excellent. Residents and their families are confident that their concerns will be listened to and acted upon in an objective and timely manner. Procedures and training available to staff supports the protection of residents from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are policies and procedures in place to ensure that complaints are dealt with effectively. Two residents said that if they had a complaint they would go to their key worker, team leader or the owner. Speaking with care staff, they were able to demonstrate that they would know if a resident was concerned or unhappy about their life in the home. Replies demonstrated that they had a good understanding of the residents in their care. Staff responses include observing the resident’s body language and their tone of speech when in conversation. Neither the Commission nor the home have received any complaints since the last inspection. Responses in questionnaires from people who use the service include: “Easy to talk to and very understanding.” A policy and procedure detailing the action to be taken by staff to ensure the protection of vulnerable adults was examined. Speaking with residents they expressed that they felt safe in the home and residents were seen to be relaxed with each other and the staff. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 17 Training records examined show that staff have attended training related to the protection of vulnerable adults. Discussions with staff show that they are aware of their role and responsibility in reporting any suspicion of, or actual harm to residents. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26,27, 28, 29 and 30 Quality in this outcome area is good. The environment in which residents live provides a homely, private, comfortable and safe home, which meets their needs, individual lifestyle and level of independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner of the home provides accommodation and support services for up to seven adults with varying types and stages of dementia. The home is a domestic dwelling situated in a residential area of Atherstone near to shops and other local facilities. It was a nice day and some of the residents and relatives were sitting in the garden. The home and garden are well maintained a maintenance man is employed by the home and he was present in the home on the day of the inspection to paint the fence around the enclosed garden. The home presents a homely environment, which meets the needs of the resident’s. One of the residents followed through the case tracking process showed the inspector around the home. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 19 Each resident has their own bedroom six of these have separate en suite facilities consisting of a sink and toilet and one bedroom has a sink in the bedroom. Two of the bedrooms were viewed with permission both were additionally furnished with personal items. The resident undertaking the tour said that they were able to go to their bedroom and access other parts of the home whenever they wanted to. The resident had access to a computer in their bedroom and was able to access a further computer in the home. The main lounge area is designed to provide an open plan area. The décor is light and airy with the minimum of furniture suitable to meet the needs of residents. The room is easily accessible to all residents with easy access to the kitchen, dining area and garden. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36 Quality in this outcome group is good. Recruitment practices, employment of permanent trained and experienced staff promotes safety, consistency and continuity for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with residents showed that they were clear about who the individual staff are in the home and were able to say which member of staff was their key worker. There was sufficient staff on duty to provide appropriate care for the residents living in the home. One of the members of staff on night duty is a sleeping-in shift, which is suitable for the residents living in the home. Observations during the inspection visit showed that staff are competent, effective and discreet when supporting residents in their care. Residents were relaxed with staff members and interaction between staff and residents were relaxed and comfortable. Staff spoken with were happy in their individual roles. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 21 One member of staff spoken with was knowledgeable about the resident for whom she is the key worker. The care worker talked about the care the resident received, especially in relation to nutrition explaining what she would do if the residents eating habits deteriorated. Comments received from family members about staff in the home include: “…I have found the staff to be helpful and approachable and the care of my father to be of a high standard.” Staff files examined and conversations with three members of staff, which includes the manager provided evidence of training attended. A recently appointed member of staff who had been working in the home for nearly six months was able to explain his induction process. The induction process is linked to the skills for care common induction programme. This programme provides an identified assessment criteria, which links to the National Vocation Qualification (NVQ) level 2 in care. The member of staff was happy to be working in the home and is due to start his NVQ level 2 later this year. Training and courses completed include dementia care, moving and handling, infection control, food safety and fire training. Staff are also undertaking protection of vulnerable adults training. A copy of the workbook compiled by Warwickshire Social Services and titled ‘Recognising and responding to abuse and neglect’ was examined. Staff were enthusiastic about training. The files for staff working at this home are stored safely at the sister home Merevale House, which is the central office for the two homes. One member of staff had been recruited since the last inspection. The files for two staff were examined one recently appointed care staff and one for a member of staff that had worked in the home for some years. Information contained within the files showed that recruitment procedures were in good order and that appropriate checks have taken place before new staff are employed to work in the home. Procedures carried out include Criminal Record Bureau checks, (CRB) and obtaining two appropriate references. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43 Quality in this outcome group is good. Management and operation of the home ensures the safety of residents at all times, which supports and increases their self-worth and quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A team leader manages the home with external support from the owner of the home who is also the registered manager for the home. The owner advised that plans would be for the team leader to undertake the Registered Manager Award (RMA) and then apply to be the Registered manager for the home. Observations, conversations with residents and staff showed that the home is well managed in a homely but structured way. There are clear lines of management and residents are aware of the responsibilities of each member of staff. Two residents talked about their key worker and the things they did for them. 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 23 Through the course of the inspection and during discussion, the team leader and owner of the home was able to demonstrate that they have good knowledge of the residents and service offered. The team leader and staff involved residents through meetings, general conversations in discussing and suggesting what improvements could be made in the home to provide better outcomes for residents. Minutes of a meeting held earlier this year were certain the discussion evidenced within the document show that a range of activities and events were discussed. The management team have started to update care plan documentation to make the paperwork more accessible to staff and easier to use. All records seen as part of this inspection visit relating to health and safety and safe practices include fire equipment checks these were up to date and fire alarms had been checked. PAT testing on electrical equipment used in the home was up to date. Staff have received up to date training in Fire Safety, Basic Food Hygiene, Moving and Handling and Infection Control. Observation of the environment during a tour of the home, care practices and discussion with resident’s and staff evidence that the premises were safe and secure. Residents were seen to move around the home safely and easily and had the aids and adaptations necessary to do so, including, a stair lift and hand rail where needed. The management team have developed systems for monitoring the quality of the service. Paperwork examined show that residents are invited to be involved in the interview and appraisal of staff. 164 Coleshill Road DS0000004312.V336354.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 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 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 3 164 Coleshill Road DS0000004312.V336354.R01.S.doc Version 5.2 Page 25 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 164 Coleshill Road DS0000004312.V336354.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: 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 164 Coleshill Road DS0000004312.V336354.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. Re-publishing this information is in breach of the terms of use of that website. 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