Inspection on 18/12/06 for 178 Wylds Lane

This inspection was carried out on 18th December 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

178 Wylds Lane 09/01/06

178 Wylds Lane 27/07/05

178 Wylds Lane 11/01/05

178 Wylds Lane 22/06/04

178 Wylds Lane 26/01/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Wylds Lane, 178 178 Wylds Lane Worcester Worcestershire WR5 1DN Lead Inspector R McGorman Unannounced Inspection 18 December 2006 2:00 th Wylds Lane, 178 DS0000018704.V306648.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 Wylds Lane, 178 DS0000018704.V306648.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. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wylds Lane, 178 Address 178 Wylds Lane Worcester Worcestershire WR5 1DN 01905 764201 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 Mrs Breda Goulding Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home is primarily for people with a learning disability who are under 65 years of age. The Home may also accommodate people with an additional physical disabiity and those who are over 65 years of age. 9 January 2006 Date of last inspection Brief Description of the Service: 178, Wylds Lane is registered to provide residential care for up to 4 adults who experience a learning disability, and who may have additional health needs. The range of fees varies between £1,100 and £1,250 per week. The premises is a large, detached, purpose-built bungalow, situated close to the centre of the City of Worcester, with easy access to public transport and a range of amenities and facilities. The home is owned and run by Dimensions (UK) Ltd., and is part of the New Dimensions Group, which, as the parent company provides strategic direction and a range of functional support services. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices, and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. The visit was unannounced and took approximately 3 hours, when some time was spent with service users, mostly observing their interactions with the people who support them, as they are not easily able themselves to communicate their opinions verbally. During conversations with staff, comments were made about what it is like to work for the organisation and also at the home. The care records of service users were seen, and discussion about the content held with the acting care manager, Mrs Breda Goulding, who was on duty during the inspection. The care plan of one service user was inspected in detail for case tracking purposes. A tour of the building was undertaken and the records kept in respect of the maintenance of equipment, and safe working practices were also seen. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 6 What the service does well: Detailed information about the home is provided for service users and is reviewed regularly. The families of service users, or their representative are also supported and their involvement with the home is encouraged. The care that is provided at the home revolves around the service users who live there, and their complex needs are understood and met in an appropriate way. The staff work well with other professionals and agencies with obvious benefit to service users. The commitment of staff in supporting and enabling service users, to achieve as much as they are able is commended. A high standard of personal and health care is also provided for each person living at the home. The activity programme enables each service user to do the things they enjoy and to make choices about their daily lives. A vehicle is provided to enable each person to be involved in the local community, and to enjoy trips and holidays further away from home. The building is well maintained and the house is nicely decorated, and is also safe, comfortable and clean. The Organisation follows good recruitment and selection procedures, and is clear about the support, training and development for the staff it employs. Staff confirmed that they have good training opportunities. The records and documents at the home are well maintained, and kept safely. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? There is an ongoing commitment from everyone involved at the home to maintain and develop the service. The information provided for service users has been reviewed and updated recently to a very high standard, and is produced in a format that each person can understand. The care planning procedures are being reviewed regularly and are adapted to suit the individual needs of service users. Protective covers have been provided for the beds of service users requiring bed rails. Many items of equipment have been replaced to ensure that high standards are maintained within the home. Staffing levels have improved and the team is more settled, with benefit to both service users and staff. Training has been provided for staff on dealing with mental health problems, and also on death and bereavement. The manager has achieved registration, and continues to develop her skills. Quality is monitored and surveys done, to ensure that service users are able to say how they would like the service to develop. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 8 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. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 9 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 Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Appropriate documentation is in place to enable prospective service users to make an informed decision about their future care needs. The assessment process is detailed and thorough to ensure that the appropriate care can be provided. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 11 EVIDENCE: The Statement of Purpose and the Service Users Guide, provide detailed information for residents and their families, about the services and facilities available at the home. These documents were reviewed recently by the Registered Manager, and an appropriate format for service users has been produced to a very high standard. The information recorded about individual service users is kept by them, unless they have made other arrangements with staff. Their personal information is reviewed regularly, to ensure that it accurately reflects all the specific aspects of the care that can be provided. The admission procedure is detailed and thorough and includes assessment by staff from the home, and also a Community Care Assessment undertaken by the social worker. There have been no recent admissions to the home Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 12 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 good This judgement has been made using available evidence including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. The key-worker system ensures that service users living at the home are supported in making choices in all areas of their lives. Service users are helped to take part safely in the various activities of daily living and to enjoy new opportunities. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 13 EVIDENCE: An individual plan of care is produced for each service user, based on the initial assessment undertaken during the admission process, and these are all very well developed at the home. There was evidence in the care plans, of effective person centred care being delivered, and the positive interactions observed between staff and service users were pleasing to observe. The person centred approach to care planning is being implemented, and the involvement of each service user in making decisions about their daily life in the home is encouraged by staff. The details recorded about each service user are discussed with them and their family, or a representative. Each service user has a key worker who has responsibility for ensuring that appropriate care is provided. Monthly meetings are held with the service user, and any changes are monitored and recorded. The special communication needs of service users are identified, and understood by staff. The service users living at the home are not all able to communicate verbally, although everyone can make themselves understood in different ways. Staff are able to identify the individual wishes and needs of each service user, by interpreting their reactions to every situation. Risk assessments are completed, in relation to the premises, to the activities undertaken, and any restrictions imposed, and also in respect of every aspect of the life of each service user. There is also evidence in the care plans of the ongoing review of risk assessments. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected 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 excellent This judgement has been made using available evidence including a visit to this service. Service users help to plan their lives. Each person takes part in various activities, both within and outside the home, and they are able to choose what they want to do and when, which helps to ensure that their rights are respected. The opportunities made available to service users, and their regular contact with family and friends, enables them to live a full and satisfying life as far as possible. There is a flexible approach to the provision of a healthy diet, and service users are encouraged to decide what to eat and when. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a wide range of leisure activities. The programme of activities for each person is varied and flexible, and reflects their preferences. A detailed record is maintained. One resident attends a local day centre, when well enough, and does some creative pottery, and another service user enjoys cooking, and will often make cakes for the staff. Another person is very involved with a local church, and regularly attends the Sunday services. She also enjoys classical music and choir singing, and goes to concerts and to the cathedral. Various outings are organized and these can be planned in advance, for example, to the Walsall Illuminations, or on the spur of the moment, someone might suggest going out for a ride in the car. In addition some service users like ten pin bowling, going to a disco, or to the pub for a meal and a drink, or just shopping in town. Parties are also a feature of the home, and 180 Wylds Lane is well known for organizing a good ‘Knees-up’. Holiday destinations this year have included the Norfolk Broads, Disneyland Paris, Blackpool and Burnham-on-Sea. Links with family and friends are promoted. Staff offer support to both the service user and their family, and they are encouraged to be involved with the home. Service users all have relatives, therefore advocacy services are not used at present. Two visitors to the home were spoken to at length, and their comments about the home, the care provided and the support and commitment of staff were very positive. They referred to the consistent approach of staff, the good level of communication, and how they were encouraged and enabled to attend any events, or just to visit, and to be involved in everything that was going on at the home. The mother of one service user explained how she was given great peace of mind because of the wonderful way her daughter was looked after. The arrangements regarding the provision of food reflect the individual likes and dislikes of each service user. General food stocks for the home are purchased each week, with the assistance of service users, who decide on their individual meals, and have their own cupboard and freezer drawer for storage. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 good This judgement has been made using available evidence including a visit to this service. The care that is provided at the home revolves around the service users who live there, and their complex needs are understood and met in an appropriate way. The manner in which support is provided by staff helps to ensure that the rights of service users are respected, when meeting their personal and health care needs. The health of service users is promoted and they are protected, by the regular medication reviews, and by the high standards maintained when giving medication. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 17 EVIDENCE: The personal and healthcare needs of service users are well documented, and there is evidence to show how staff understand and respond to them in an appropriate way. Personal care is provided in privacy. Reviews are undertaken regularly with all service users to determine their specific needs. The healthcare of service users is closely monitored, and additional specialist support and advice is sought from the primary health care team, and other health professionals, when necessary. Health Action Plans have been implemented for all service users living at the home. One service user who has been unwell has needed hospital treatment recently on two occasions. Routine eye care, podiatry and dental treatment are also arranged. Reviews of the mobility needs of service users were arranged with a view to making improvements where possible. The need for a motorised wheelchair for one service user, and the replacement of existing wheel chairs for other people have been identified. The involvement of the Community Physiotherapist was requested to assist service users to obtain the appropriate equipment. There have been some recent issues with the supply of continence equipment for a service user, when the supplier failed to deliver the usual amount. The Registered Manager said she had experienced a lack of co-operation when trying to resolve the situation, and additional supplies had to be purchased from elsewhere. The matter is being dealt with in an appropriate manner by the home on behalf of the service user. The sleeping arrangements for one service user, who was identified as being at risk, have been reviewed, in order to ensure her comfort and safety. Several options were tried, including a specialist bed, and a satisfactory solution has now been found. Medication arrangements at the home are satisfactory, although a new storage cabinet is needed. A Monitored Dosage System is in use, and regular checks by the pharmacist are undertaken. The Medication Administration Records had been completed appropriately, and a detailed profile, together with a photograph was completed for each service user. A list of the side effects of the medication taken by service users is kept in the medication file. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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 a visit to this service. People who use the service are enabled to express any concerns, through the complaints procedure. Staff know what they should do to protect service users from all forms of abuse. EVIDENCE: A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately. The document has been produced in a format that is understandable to service users. There had been one complaint made to the home, and this was dealt with appropriately by the organisation. Comments and compliments received at the home are also recorded, which helps to give a balanced view of the service. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults, and all staff had received training as part of their induction process. Discussions with staff showed they had a clear understanding of the issues relating to abuse, and also to their individual role as an advocate for service users. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable and clean, and ensures as far as possible that the safety and wellbeing of service users is promoted. The décor and furnishings are in good condition, and provide service users with an attractive and homely place to live. The equipment provided for service users enables them to be as independent as possible. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 20 EVIDENCE: The premises at 178, Wylds Lane is a large detached, purpose built bungalow, which is maintained to a satisfactory standard, and is suitable for its purpose. There are four single occupancy bedrooms for service users, which all comply with space and furnishing requirements, and protective covers are provided for the bed rails on the beds of service users who require them. The rooms are furnished to reflect the personality of their occupants, and some have sensory equipment, specific to the needs of the individual service user. Appropriate aids and adaptations are provided for the use of service users, and these are regularly maintained. The communal areas of the home are spacious and airy, nicely decorated and comfortably furnished. There are three communal rooms, offering choice for service users. These consist of a spacious lounge, a large kitchen/dining room, and a further sitting room. The gardens are accessible to service users, and have benefited from further attention during the summer months. There is also a patio that can be accessed through a French window from the lounge. The home is clean and free from offensive odours. Procedures are in place for the control of infection, and staff are trained in health and safety matters. Contracts are in place for the servicing of equipment at the home, although the repair of an extractor fan in the bathroom is outstanding. There have been several items replaced recently, including the cooker, the microwave, the washing machine, the tumble dryer, the fridge/freezer and the dishwasher. Redecoration of the hallway and corridors has also been undertaken, and some carpets have been cleaned. The need for a new carpet to be fitted in the main lounge was identified, as it is rather worn in places. There are no outstanding requirements following a recent visit from the Environmental Health Officer. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected 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 a visit to this service. The home has an experienced and competent team of staff, who are able to ensure that the needs of service users living at the home can be effectively met. Appropriate recruitment procedures ensure that service users are supported and protected by staff. The extensive training programme available to staff ensures that they are competent in their work Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 22 EVIDENCE: Dimensions provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. Service users and staff benefit from the thorough recruitment and selection procedures that are implemented by the organisation, which include a commitment to equal opportunities. Criminal Record Bureau checks are completed prior to an appointment being confirmed, and verbal and written references are also obtained. Staffing arrangements at the home are now more settled although there have been some changes during recent months. Several staff have been on maternity leave, some staff have transferred to and from other Dimensions’ homes in the area, one member of staff has been on extended sick leave, and some new employees have also been recruited. The Registered Manager confirmed that staffing levels have been maintained, but she has needed to use agency/relief staff at times, particularly to provide cover for staff from the home when giving additional support to a service user who has spent some time in hospital recently. A training programme is in place at the home, and the training needs of staff are regularly reviewed. Staff confirmed the training courses they have recently attended, and said they are given ‘good training opportunities.’ A record is maintained in respect of the training received by each member of staff. All staff have undertaken the specialist, care-related training previously identified, on caring for people with mental health problems and also death and bereavement. A training course on Total Communication, which was postponed recently, is being re-arranged for the New Year. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Satisfactory management arrangements at the home, enable service users and staff to benefit from a well run home. The rights of service users are safeguarded by the effective policies and procedures, together with appropriate records that are maintained at the home. The health, safety and welfare of service users is promoted and protected in respect of all safe working practices Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 24 EVIDENCE: The care manager Ms Breda Goulding has many years experience working with this client group. She was deputy manager at 178 Wylds Lane for many years, and was registered as the manager 12 months ago. She has good communication skills, and has a clear understanding of the role, and her responsibilities. She is undertaking the Registered Managers Award, and she also continues to update her knowledge and awareness in relation to the needs of people who have a learning disability. There is clear evidence of effective person centred care being delivered, and the home is being managed in a manner that is fully inclusive of service users. The positive interactions observed between staff and service users are pleasing to observe. The home very obviously revolves around the people it is supporting. An annual development ‘PATH’ plan has been produced which involves the whole home, and forms part of the quality assurance programme for the Organisation. The team identifies where they are at, where they want to be in 12 months time, who they need to help them to get there, the building bricks and the strengths required, and who does what. Reviews of achievements take place every 3 months, and the outcomes are measured. The Quality Monitoring Officer visits the home on a regular basis, and undertakes an audit of the various systems, some of which are being standardised following the addition of several new homes to the group. Policies and procedures are produced by the Organisation, and staff confirmed they are familiar with the content. An officer is employed by Dimensions to advise on health and safety matters, and the home also has a health and safety representative, with delegated responsibility for ensuring that risk assessments are implemented and reviewed regularly. The records checked during the inspection were completed to a satisfactory standard, and they are securely kept. Regulation 26 reports are submitted to the Commission on a regular basis. Routine maintenance and servicing of equipment is done, and temperature checks are recorded. The accident records were seen to be in order, and appropriate information is sent to the Commission. The home has not received a recent visit from the Fire Safety Officer. The Fire Log Book was seen, and the appropriate checks have been undertaken with the required frequency. The Fire Risk assessment has been reviewed recently. Fire awareness training is undertaken, but not regularly every three months. The manager was also reminded of the need to ensure that a fire drill is organised every six months and that a full evacuation should be done annually. Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 25 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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Wylds Lane, 178 DS0000018704.V306648.R01.S.doc Version 5.2 Page 26 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 YA29 Regulation 23(2)(c) Requirement The dysfunctional extractor fan in the bathroom must be repaired or replaced Timescale for action 31/01/07 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 2 3 Refer to Standard YA20 YA24 YA42 Good Practice Recommendations The arrangements for the storage of medication should be reviewed to ensure that adequate locked facilities are provided Consideration should be given to the replacement of the lounge carpet Arrangements should be made for staff to receive fire awareness training, at least every 3 months, including fire drills and practices at suitable intervals – at least every six months to comply with the Regulatory Reform (Fire Safety) Order 2005 Wylds Lane, 178 DS0000018704.V306648.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 Wylds Lane, 178 DS0000018704.V306648.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!