Inspection on 06/06/08 for 18 Aqueduct Road

This inspection was carried out on 6th June 2008.

CSCI found this care home to be providing an Good service.

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

18 Aqueduct Road 26/09/06

18 Aqueduct Road 28/02/06

18 Aqueduct Road 26/05/05

18 Aqueduct Road 22/11/04

18 Aqueduct Road 10/08/04

18 Aqueduct Road 22/12/03

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 27/09/2008.

CARE HOME ADULTS 18-65 18 Aqueduct Road 18 Aqueduct Road Shirley Solihull West Midlands B90 1BT Lead Inspector Justine Poulton Unannounced Inspection 6th June 2008 11:00 18 Aqueduct Road DS0000043650.V366005.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 18 Aqueduct Road DS0000043650.V366005.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. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 Aqueduct Road Address 18 Aqueduct Road Shirley Solihull West Midlands B90 1BT 0121 474 3197 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.robinia.co.uk The Robinia Group PLC Ms Christine Higgins Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: The service at Aqueduct Road consists of a domestic four-bedroom house located in a residential area of Shirley, Solihull. It is registered to accommodate two people who have a learning disability. The current residents also have a diagnosis of autism. The property is within walking distance of a local park and other community facilities in the locality. Solihull Town Centre is accessible by bus as is Birmingham City Centre. Shirley Railway Station is a ten-minute walk from the Home. The premises consist of two single bedrooms one of which has an en-suite bathroom. There is a bathroom on the first floor with a toilet and a toilet is available on the ground floor that is shared on a communal basis. The home has a communal lounge, dining room, kitchen and sensory room. Upstairs is an office/staff sleep in room. Within the house but accessed separately is the managers office. There is a rear garden where a wooden decking structure is partially constructed. The garden is well screened by shrubbery and trees providing privacy for the people that live in the home. The home does not provide off road parking and there is limited parking along the road. There is no adapted access to the property and people require good mobility to access the home’s bedrooms which are all situated on the first floor. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out to establish the outcomes for people living in this home, and to confirm whether they are protected from harm. Identified key standards were looked at, along with a review of the organisations progress towards meeting any requirements made at the previous inspection of this service. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection. Both people living in the home were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for people. Records, policies and procedures were examined and the environment was looked at. Both of the people living in the home were at home for all or part of the inspection. The inspector would like to thank the people resident in the home, the manager and staff for their hospitality and co-operation during the inspection. What the service does well: This home consistently meets the key national minimum standards ensuring positive outcomes for the people who live there. Each person living in the home has an individual care plan which details the levels of care and support required, along with how they prefer the support to be provided. Detailed risk assessments are also in place that ensure that people are able to live the lives of their choosing within a safe framework. The organisation provides 24 hour staffing as an alternative to formal day centres or colleges. Where people choose not to attend a day service or college course, they are supported to access activities, hobbies and leisure pursuits as they wish. Contact with relatives and friends is promoted by the home, and is seen as being of paramount importance where applicable. A healthy diet is promoted within the home. People are supported with menu planning, and are encouraged to participate in food preparation if they choose. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 6 Special diets are catered for, and staff are careful to ensure that particular diets relating to religion are maintained. People’s personal support and care needs were clearly documented, as were their health needs, along with evidence to confirm that these are addressed appropriately. The people who live in this home rely on the staff to manage their medication for them. This is done on an individual basis, and procedures and practices appeared safe during the inspection. The home has a complaints procedure in place. Staff were able to describe how they interpret when someone is not happy from the non verbal clues given. The recording of complaints received was appropriate. A policy on the protection of vulnerable adults is also in place in the home. Staff were aware of their responsibilities should abuse be alleged or suspected. The home presented as clean and hygienic with no unpleasant or offensive odours apparent. The home employs sufficient staff to meet the needs of the people living there. The organisation offers a comprehensive training package for staff. Staff recruitment procedures ensure that people are safeguarded. The home is managed by a competent and experienced manager. Health and safety is managed appropriately. What has improved since the last inspection? Work has been undertaken to ensure that the requirements made at the last inspection have been addressed as follows: • All staff receive full recruitment checks prior to commencing work at the home. For those with a satisfactory POVA first check, but that are awaiting a satisfactory criminal records bureau check, they commence work in the home under strict supervision. All of the required health and safety issues have been addressed. A person qualified in first aid is on duty on each shift. The on call arrangements have been addressed following the change in the homes management. • • • 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 7 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. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): x The quality in this outcome area was assessed as good at the last inspection of this service. People’s needs are assessed prior to admission to assess the home’s capacity to best meet the needs of individuals admitted to the home. This judgement was made at the last inspection of this service using available evidence, which included a visit. EVIDENCE: No new people have been admitted to the home since the last inspection. The judgement for this outcome group was deemed to be good at that time therefore it remains the same as it was not necessary to look at key standard 2 on this occasion. 18 Aqueduct Road DS0000043650.V366005.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality of this outcome area is good. Each person has a detailed care and support plan which is flexible and reflects individual needs. Staff provide people with the appropriate support they need to make decisions about their own lives. People have a variety of pertinent risk assessments which identify how risks will be managed safely. The judgement has been made using available evidence including a visit to the service. EVIDENCE: Both of the people that live in the home have comprehensive care and support documentation, however it was not easy to access as it was spread around a number of files and much of it was being duplicated unnecessarily. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 11 Each person has a set of targets and aspirations accompanied by a progress sheet which was reported on monthly by their keyworker until March of this year, when this appears to have lapsed. Areas covered within their targets and aspirations include the development of skills of positive interaction, maintaining and developing personal care skills, developing domestic responsibilities and reducing anxieties. It was noted that the support plans of each person were reviewed and updated in April 2008. In addition to the targets and aspirations of each person were completed risk assessments pertinent to each individual. These included the use of public transport, absconding, throwing objects whilst agitated and public safety whilst out in the community. Again these were all reviewed and updated in April of this year. It was noted that the information pertaining to the people living in the home was duplicated throughout a considerable number of files for each person. The manager said that he has plans to streamline the support planning process to make it easier more accessible and user friendly for both the people they belong to and the staff using them. Both of the people that live in the home have communication difficulties, which make it hard for them to make their needs and wishes known in a verbal manner. It was apparent from watching them with the staff members on duty that they are competent at making their wishes known in a non verbal manner and that the staff are able to interpret these as appropriate. For example, during the inspection one person fetched his shoes and put them on to indicate that he wanted to go out, whilst the other put on his coat. The home has a high staffing ratio to ensure that both people are able to do what they choose when they choose as one of the methods of preventing any agitation and distress to both young men. 18 Aqueduct Road DS0000043650.V366005.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. People are offered a variety of home and community based activities to choose from, based on their previously demonstrated preferences. Relationships with families and friends are promoted and supported. A healthy, nutritious diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both of the people living in the home have the opportunity to attend college courses or day services if they wish. One person chooses not to attend any form of formal day service provision or college, and is supported by staff at the home to access activities of his choosing. The other person does attend college on a part time basis, and is also supported by staff from the home with 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 13 accessing other activities. Each person had a timetable of activities in place which detailed things such as going shopping, swimming, to the cinema, bowling, college and car, bus or train rides. In addition to the timetable, each person also has an activity monitoring form that is completed on a weekly basis. Both of the people who live in the home are assessed as needing two to one support when they go out. This is provided on a daily basis, however, one person has extra support provided between the hours of 10:00am until 4:00 pm, which the manager said is not always appropriate to his needs, as he may not wish to go out during these hours, preferring instead to go out in the evening when the extra support is not available. The manager stated that this is being looked into to try and make this additional support more flexible and person centred. Both people who live in the home are supported to maintain contact with their families and friends either through visiting, being visited or via the telephone. The staff also keep in contact with relatives, ensuring that they are invited to review meetings, and any special occasions that are celebrated in the home. The home has a functional kitchen which is in need of refurbishment as it looks tired and worn with broken or missing drawer fronts and cupboard doors. Meals are planned on an individual basis and reflect individual preferences and dislikes, special diets and healthy eating. One person is from a Muslim background, and his family have requested that he eat a diet in keeping with the family religion. Information within this persons support plan confirmed that Halal meat is purchased for him, and foods forbidden for religious reasons are not provided. A Halal (allowed) and Haram (forbidden) food guide is in place for staff to follow. Menus are discussed with the people living in the home on a weekly basis, and records of foods provided and foods eaten were available. Food stocks are purchased on a weekly basis and include plenty of fresh fruit and produce. It was noted that the kitchen was kept locked when a member of staff was not in it. It was advised that this was because the people living in the home would put themselves at risk from eating raw or uncooked foods if it was left open. It is recommended that this be reassessed given the general minimum staffing levels of three staff to two residents, and the more usual levels of four staff to two residents. Although the kitchen is in need of refurbishment, it was clean, tidy and well stocked on the day of the inspection. 18 Aqueduct Road DS0000043650.V366005.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, 20 Quality in this outcome area is good. Care plans in place ensure that personal support is consistent, reliable and responsive to peoples needs. The healthcare needs of people are assessed and recognised with evidence of specialist services being readily available to them. Medication policies and procedures ensure that medication is managed safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has their personal care and support needs documented in their support plans. Both people require a mixture of hands on support and prompting, and the staff team work with them to ensure that they are able to develop and maintain their independence in this area. Information was available to confirm that people continue to be offered routine healthcare appointments such as the dentist, optician and chiropodist at the 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 15 recommended intervals. Information was also available to demonstrate that more specialised healthcare needs are addressed as appropriate, such as the attendance at well man appointments along with psychology and clinical behaviour nurse specialist services. Medication is supplied to the home by Boots in blister packs that are accompanied by medication administration records (MAR). The home stores medication in a locked cabinet in the staff office / sleep in room. Neither of the two people resident in the home self administer their medication. The staff team do this on their behalf, following training in the use of multi dispensing systems provided by Boots, and medication administration training. The team leader is responsible for booking in, reordering and returning medication. Examination of the MAR charts confirmed that they were completed accurately and did not raise any concerns on the day of the inspection. It was noted that the medication cabinet was too small for the amount of medication supplied to the home, especially on a delivery day. The manager said that he is looking into with replacing the existing cabinet with a larger one or purchasing another one so that each person has their own. 18 Aqueduct Road DS0000043650.V366005.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, 23 Quality in this outcome area is good. The home has a satisfactory complaints system and can demonstrate that people’s views are listened to and acted upon. There are policies and procedures in place for the safeguarding of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has the organisations policy on complaints in place. A complaint log was in place in which one complaint had been logged recently. Staff spoken with said that the limited communication abilities of the two people resident in the home makes verbalising their concerns or complaints difficult for them, but they are able to demonstrate their unhappiness with something via their non verbal behaviour. Staff confirmed that they know both men well enough to be able to determine what they are communicating. No complaints have been received by us since the previous inspection. An organisational policy on protection from abuse was also available within the home. Training records looked at confirmed that all of the staff need either training or refresher training in safeguarding vulnerable adults. Staff spoken with were able to clearly describe what steps they would take should abuse be 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 17 suspected, witnessed or disclosed however, they stated that they had received this training either via their induction programme of NVQ qualification. There have been no allegations of abuse made to us since the last inspection. 18 Aqueduct Road DS0000043650.V366005.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, 30 Quality in this outcome area is adequate. The home provides a clean and reasonably comfortable environment for people to live in. An improvement in the décor would further enhance the environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service at Aqueduct Road consists of a domestic four-bedroom house that is not distinguishable as a care home from the other houses in the road. The accommodation for the people living there consists of two single bedrooms one of which has an en-suite bathroom. There is a bathroom on the first floor with a toilet and a toilet is available on the ground floor that is shared on a communal basis. The home also has a communal lounge, dining room and 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 19 kitchen. The remaining two bedrooms are used as a sensory room and the staff office/sleep in room. Within the house but accessed separately is the managers office. There is a rear garden with wooden decking. The garden is well screened by shrubbery and trees providing privacy for the people that live in the home. The home does not provide off road parking and there is limited parking along the road. The home would benefit from redecoration throughout as it is either worn or damaged. Similarly, some of the furniture would benefit from being replaced, as the people resident in the home have damaged it at some point. A newly constructed secure television cabinet was being installed in the lounge on the day of the inspection to ensure that the television was not damaged in the future. Both bedrooms were looked at, and it was explained that they contained only what each person would tolerate. Given this they were comfortable and clean and there were elements of personalisation dotted around. There is no adapted access to the property and people require good mobility to access the home’s bedrooms which are all situated on the first floor. The homes washing machine and tumble dryer are situated separately from the kitchen but have to be accessed via this room. Procedures are in place to ensure that dirty laundry is transported via the kitchen in a safe and hygienic manner. Although the décor of the home is worn, the home was clean, tidy, hygienic and free from any unpleasant odours during the inspection. 18 Aqueduct Road DS0000043650.V366005.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): 32, 34, 35 Quality in this outcome area is good. People benefit from an enthusiastic staff team who receive appropriate training and work towards common goals. People are supported and protected by the homes recruitment policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The completed Annual Quality Assurance Assessment (AQAA), provided by the manager prior to the inspection says that the home employs 12 staff members. Training records provided list nine permanent staff, one bank staff and two agency staff. The manager confirmed that the agency staff were in the process of becoming permanent staff. Rotas looked at and staff spoken with confirmed that there were generally three staff on duty during the day, with an additional staff member between the hours of 10:00 until 16:00 to ensure that each person has two to one staffing and can participate in activities of their choosing. The manager said that the additional six hours staffing for one 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 21 person was restrictive however, as the person concerned may choose not to go out during these times, and then want to go somewhere in the evening. This was being looked at with a view to making it more flexible. The files of four staff were checked. The records available within these confirmed that staff have been subject to POVA first checks (vetting checks) where necessary and Criminal Record Bureau checks had been applied for prior to staff starting work at the home. In all cases two written references had been sought by which to assess staff suitability for the job. The records demonstrate that potential staff are taken through a proper interview procedure prior to being considered for a post. The organisation places great store on valuing its staff team by providing consistent training to enable them to do their jobs to the best of their abilities. Staff training records confirmed that approximately 50 of the staff team were up to date with their mandatory training such as first aid, food hygiene and fire safety. Six staff have completed the Learning Disability Qualification induction programme and three staff have completed the foundation programme. In addition three staff have completed their NVQ III. Training in subjects such as behaviour management, epilepsy, autism and makaton are also provided for staff. Staff spoken with said that the training they received was “good”. The manager said that he is aware of the training needs of staff, such as safeguarding vulnerable adults and ensuring that all of the team are up to date with their mandatory training and is in the process of addressing this. 18 Aqueduct Road DS0000043650.V366005.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): Quality in this outcome area is good. The leadership, guidance and direction provided to staff ensures people receive consistent quality care and support. People are consulted about the quality of life within the home. Health and safety is managed appropriately This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management status of the home has changed since the last inspection of the service. The registered manager has moved onto a permanent senior position within the organisation, and the management of the home has been taken over by a registered manager of another of the organisations homes 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 23 within the Birmingham area. The manager has responsibility for both services and stated that he will be dividing his time equally between the two, and is always available on his mobile phone should the staff from either service need to contact him. The quality of the service provided to the two people who live in the home is monitored via a number of methods. Regular regulation 26 visits are undertaken by the provider to assess the service people are receiving; staff have regular team meetings; weekly meetings are held with the people living in the home which are recorded and anything that requires acting upon is undertaken and staff have regular recorded supervision sessions and more informal on the job supervision. The organisation also has a quality assurance programme. Satisfaction questionnaires were sent to families last year however the manager said that they hadn’t been given to the people living in the home as the previous acting manager had felt that they were not appropriate in their current format. The manager stated that he is planning to devise an appropriate alternative that will be meaningful to them in order to gauge their satisfaction with the home or otherwise. Information was available to demonstrate that the health and safety of people living in the home, staff and visitors is maintained. A sample of health and safety checks was taken, which included portable appliance testing, records of fridge and freezer temperatures and fire alarm points, the landlords gas safety certificate and the homes fire risk assessment all of which were up to date. 18 Aqueduct Road DS0000043650.V366005.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 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1 2 3 Refer to Standard YA23 YA24 YA35 Good Practice Recommendations It is recommended that the manager look into providing training in safeguarding vulnerable adults for all staff. It is recommended that a planned maintenance and renewal programme be instigated with regards to the fabric, furniture and decoration of the home. It is recommended that the manager provides all staff with the necessary refresher training in the mandatory subjects or fire safety, first aid, food hygiene, health and safety and manual handling. 18 Aqueduct Road DS0000043650.V366005.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 18 Aqueduct Road DS0000043650.V366005.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. 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!