Inspection on 04/07/06 for 180 Bromwich Road

This inspection was carried out on 4th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

180 Bromwich Road 28/08/07

180 Bromwich Road 06/03/06

180 Bromwich Road 07/07/05

180 Bromwich Road 22/02/05

180 Bromwich Road 14/09/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Bromwich Road, 180 180 Bromwich Road Worcester Worcestershire WR2 4BE Lead Inspector Martha Nethaway Unannounced Inspection 4 and 5th July 2006 02:30 th Bromwich Road, 180 DS0000018636.V303788.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 Bromwich Road, 180 DS0000018636.V303788.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. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bromwich Road, 180 Address 180 Bromwich Road Worcester Worcestershire WR2 4BE 01905 428030 01905 429731 H5M021johartland@mencap.org.uk H4037@mencap.org.uk Royal Mencap Society 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 Joanne Hartland Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This service is for people with a learning disability but may accommodate one person with an additional physical disability. The Home may also accommodate one named person with an additonal mental disorder. 6th March 2006 Date of last inspection Brief Description of the Service: 180 Bromwich Road is a traditional detached house situated in a residential suburb of Worcester. Shops, public transport and leisure facilities are within easy reach. The home provides care for up to six people with moderate to severe learning disabilities and occasional challenging behaviour. The registered manager is Jo Hartland. The responsible individual is Ms Janine Tregelles but line management and supervision is provided to the registered manager by Tony Hickey, service manager. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit taking place over two half days. One inspector visited to observe the midmorning and day’s schedule for service users. The majority of service users were met. Discussions were held with staff and the registered manager. Selections of records were examined. The Commission identifies that twenty-two standards are to be assessed on this occasion. What the service does well: What has improved since the last inspection? • • • The home has accessed independent support and a befriending scheme. Service users value this support. The manager implemented an infection control policy. This strengthens the area linked to health and safety. The staff training programme is able to respond to the changing needs of DS0000018636.V303788.R01.S.doc Version 5.2 Page 6 Bromwich Road, 180 service users. 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. Bromwich Road, 180 DS0000018636.V303788.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 Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to ensure all admissions are planned for through a clear assessment process. The provider will need to amend service users literature to reflect transparency of fees and any additional on costs for placements. EVIDENCE: The home has a policy for admission of prospective service users. Initially, the home is reliant on the community care assessment completed by the social worker to help inform and consider the appropriateness of the placement. There was evidence of clear guidelines in place to carry out a full assessment, once a placement at the home as being identified appropriate to meet needs. The registered manager is responsible for ensuring the service user’s application is completed and supports the family through this process. The assessment process is closely linked to Person Centred Planning (PCP) and the registered manager oversees this process. The manager was able to describe the work that takes place for planning introductory visits. Staff involved in the assessment process are available for the introductory visits where possible. All through this process existing service users are consulted, observed and gauged in relation to interactions. The Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 9 manager is responsible for ensuring the matching of the individual’s needs and with that of the group established at the home. Literature is available for prospective new service users, including a service user’s guide and a Statement of Purpose. This material is available in print format, personalised to include computer graphics and photographs of the home. The provider will need to amend existing guidance and literature to reflect the recent changes with legislation including greater transparency about fees and additional costs for services. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,& 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to ensure care is being well planned and meeting the needs of service users. The home has facilitated access to independent support and a befriending scheme. Service users valued this type of support to enable their autonomy to be fulfilled. The staff team are paying good attention to the assessment of risks and are not inhibiting service user’s choice or decision-making. EVIDENCE: Each service user has a ‘Person Centred Plan’ (PCP). This plan has been drawn up with service users involvement including consulting significant individuals, relatives and family where appropriate. The staff team and keyworkers used imaginative ways of engaging services users through this process. Service users were encouraged to be in control of the PCP meetings. Information Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 11 gained from sharing views and experiences were entered into the plans. There was variety in the plans sampled. Staff were confident with supporting this model of practice as Mencap had provided training and ongoing support with implementing PCP’s as a model to support service user’s needs. The home has in place an agreement with service users where these records will be kept. Where appropriate service users have signed these agreements. The PCP cover topics connected to providing information about where the service user lives, like and dislikes and identify areas of strength and needs. The area of inclusion covered both living in the home environment and association with the local community. How health care is assessed and met is also discussed. The PCP also include reviews and health and safety matters connected to risk. The staff team have facilitated contact with ‘Lifestyles’, an independent organisation that is supporting one service user with decisions linked to his life. The manager has proactively contacted a ‘Befriending’ organisation that are in the process of recruiting volunteers that can share common interests of one service user. The service user has been fully involved with the process and views having a brefiender as a positive experience. The home has good system in place for the management of financial matters linked to service users. Records are audited and the manager reported that staff are good with complying with money management protocols. Restricting service user’s liberties are assessed and are only considered if vulnerability or exploitation issues are considered too great. The home has a clear policy for risk assessment and restrictions interrelated to quality of life expectations. The registered manager is the appointee for service user’s incoming and outgoing payment and Head Office finance department audits these. The home’s capacity to assess areas related to risk and vulnerability is good. Risk assessment were found to be well organised, coherent and showed a good understanding of safety issues. The manager is ensuring that all staff receive risk assessment training. All risk assessments are reviewed and amendments are recorded. The manager has ensured all care staff are familiarised with risk assessments by discussions in team meetings. A matrix tool is used to monitor risk assessment review dates. No review lapses occur. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16, &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for organised activities and supporting adult education is well carried out. The staff team are confident with supporting service user’s life skills. Contact with families is promoted and the staff group are open and welcoming. Suitable arrangements are in place to promote healthy lifestyles. EVIDENCE: The staff team implemented a more planned and coordinated approach to enable service users attendance to college and leisure based pursuits. Most of the service users are attending adult educational courses through the Worcester and Kidderminster Colleges. Only one service user is receiving input from a social education centre. Discussion with the service user indicated that he enjoyed attending the centre and the social aspects of meeting his friends. The Worcester College have a system to review student’s interest for participating in college courses. This includes identifying new courses. For the next academic year, one service user will be involved in animal husbandry and Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 13 this was viewed as a positive experience as the individual is a keen animal lover. During the day, service users are supported to use a hydrotherapy pool, a music therapy facility and a sensory garden. One service user had received a certificate for his work at the music sessions. The staff team have put good effort and consulted with service users to organise planned and scheduled events throughout the summer holidays. One staff member coordinates to ensure sufficient staff and transport are available. Practical arrangements like booking trains and venue tickets were being organised during the inspection visit. Staff knowledge of the local area and social events is considered good. Service users take part in small group activities, preferably no more then three and where possible avoid going out in large groups. Service users who share similar interests are participating in activities together. The arrangement for providing staff is flexible to accommodate meeting the needs of service users. One new member of staff made favourable comments about how varied the day can be at work and viewed this as a positive aspect of the home. Relatives and family involvement is welcomed. Some service users are visiting their relatives and stay for overnight stays. The staff team have involved the speech therapist to address the communication of individuals. All staff have attended the rolling programme of ‘total communication’. Where appropriate, signs and symbols have been used and one service user has made significant progress with choosing items associated to food. This has increased her confidence and notably her autonomy with making choices. The PCP sets out clearly, service user’s involvement with the routines and domestic tasks within the home environment. Staff encourage service users to engage with daily routines. A central component to this ethos is to enhance life skills. Menu plans were examined and staff ensure that healthy eating is promoted. Records of what is being eaten is also kept in the individual’s files. The lunchtime meal times were observed to be sociable occasions. Once a month, a theme night is organised to reflect food from different cultures. This was described as popular with service users. The dining room was newly decorated and a new dining room suite had been purchased. Risk assessment for mealtime management including choking was completed, where appropriate. The home has had involvement with the local dietician. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s needs are assessed and staff enable the diverse needs of individuals to be recognised and addressed. Health care planning and access to health professionals is carried out effectively. The management of medication is consistent with the home’s policy and procedure. EVIDENCE: The home has a policy that outlines how individual needs will be assessed and how the staff team will meet these needs. The overarching principal is consistent with Person Centred Planning. The home is open about discussing needs connected to disability, gender and communication needs. Service user’s preferred routines including morning and nighttimes are discussed in their plans. These are simple to use, documented in a bullet point format and easy to navigate around. These have been well considered in service user’s meetings and with staff group at a wider level. Areas related to risk had been well thought-out. The home operates a keyworker system thereby ensuring each service user has a named staff member to offer individualised support. The staff team aim Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 15 to spend quality time with service users. There was an excellent example of providing a ‘talk schedule’ where staff would spend 10 minutes during the evening with one service user. This offered staff consistency to meet the assessed needs of the service user. The staff team regard the PCP as working documents that are under regular review and are updated to respond to changing needs. The manager considers the skill mix of the staff team as good. There is a staff team of 13 and the majority are female carers. Three male staff provide positive male input and role modelling. The manager has recruited another male member of staff as a relief member to work as and when required. Service users are able to express their individuality through shopping for clothing. This is supported by staff and at all stages service user involvement is considered essential. One service user, through questionnaire response indicated that staff are aware of her preferred colours related to clothing. There was another good example of preplanning shopping events as one service user loathed shopping and only required a selected number of shops to be visited. The keyworker and co-worker were attuned to meeting this need. The home has a policy and procedure that addresses how health care will be supported. Each service user has a ‘ Health Action Plan’ but care staff have experienced some resistance from health care professionals completing this record. The manager is consulting with the local primary health care trust to highlight the issue. Records examined established that access to primary and secondary health care professionals is taking place. There were good examples of seeking professional input from speech therapy and community learning disability services. There were a number of plans addressing specific health needs as well as meeting communication needs. Staff are encouraging service users to take an interest in maintaining an active and healthy lifestyle. Staff have received specific training connected to Alzheimer’s and dementia care. This training was considered invaluable to be able to help address the changing needs of some service users. The home has a clear medication policy completed in 2002. The home uses the chemist ‘Boots MAR system’ and this ensures consistent care practices can be monitored with ordering, dispensing and auditing of all records. The Boots pharmacist carries out a monthly unannounced visit. No gaps were found in the case tracking records sampled during the inspection visit. All staff have obtained accredited medication training a six week in-house induction followed up by a Boots Medication Course. Staff competency is assessed and any training issues are discussed and addressed by the manager. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective processes are in place to address complaints and concerns associated with the needs of service users. Clear processes are in place to protect people who are vulnerable. EVIDENCE: The provider has implemented a new complaints and compliments procedure in March 2006. This also includes an accessible format ‘I’m talking are you listening’ to enable all service users to be able to use the complaints process effectively. Since the last inspection the complaints system had been used once. The records demonstrated that the service investigated the concern appropriately and action was taken to resolve the issue. The protection of vulnerable adults had been followed to refer an incident at the home. This has now been satisfactorily resolved. The provider has a clear policy regarding the protection of service users and a ‘whistle blowing’ policy is also available. The process for reporting incidents is clearly understood by senior staff and staff have a visual aid to remind all staff of their responsibility and duty. All staff receive training at the point of induction called ‘Protect and Respect’. The manager is to attend training linked to the Worcestershire Vulnerable Adults training. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 17 The only gap that needs attention is the expected records connected to allegations and the manager intends to rectify this. Records relating to financial recording keeping are comprehensive and follow the home’s procedures. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home environment is being well maintained. Ongoing maintenance and replacement of furniture is taking place. The manager has addressed significant issues related to infection control and maintains a clean and fresh environment. EVIDENCE: During the inspection a guided tour of the premises took place. The home employs a domestic cleaner who maintains a clean and tidy environment. Keyworkers are expected to help maintain the cleanliness of the bedroom and service users are involved with cleaning as set out in their plans. The kitchen has had a new laminated flooring laid. The dining room has been refurbished including the purchase of new furniture. Radiator guards are in place in the lounge and dining rooms in response to the provider’s own health and safety audit. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 19 There is a plan to replace carpets in the hallway and one service user’s bedroom. The manager has provided a comprehensive infection control policy. Correspondence with the local council with respect to the disposal of clinical waste is in place including a risk assessment. The manager has adopted the food standards agency’s policy to ensure the safe handling of food on the premises. Various charts are displayed around the home to reinforce good practice models. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are able to deliver good care and are working consistently within the homes stated aims and objectives. The recruitment practices are sound and well carried out. The provider should ensure telephone references are considered to verifying references. The provider is paying good attention to the continual professional development of the staff team. The training programme is able to respond to the changing needs of service users. EVIDENCE: The home employs a total staffing group of 17. The manager considers the range of the skill mix, ability and knowledge as good. The manager believes that the staff are competent and able to check things through with senior staff and act upon guidance provided. All staff are provided with a comprehensive induction that takes them through all aspects of supporting service users. The induction process is accredited to the Learning Disability Award Framework (LDAF). This ensures that all staff have underpinning knowledge related to the field of learning disability. Staff supervision and staff appraisals are organised with regularity and this was Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 21 evidenced in records. All staff appraisals are interlinked with the development plan. Royal Mencap are developing more effective methods and systems for staff and service user’s views to be shared and developing evidence of management action to address identified areas for improvement. The ‘Respond and Respect’ course covers and discusses in depth equality and diversity within the learning disability framework. Staff are also provided with training covering topics connected to challenging behaviour, mental health in learning disability, bereavement and loss, and relationships and abuse. The manager was able to demonstrate a proactive approach to organising training. For example gaps were identified in staff knowledge base linked to working with Asperger syndrome and a training event had been organised to address this area. The manager maintains a rolling programme of core training and regularly provides refresher courses. At a corporate level the priority for this year has been to implement PCP training for all care staff and this included involvement from disabled trainers. The home has a planned approach that addresses NVQ training for care staff. Six staff are qualified at NVQ level 2 or above. Two further staff are registered with the training scheme starting in Autumn 2006. It is anticipated that the target of 50 of care staff will be achieved. The recruitment records were examined and contained all the necessary records. Records were coherent and well maintained. The manager ensures a record of past training courses and a range of responsibilities are included in the pre-employment checks. Gaps related to employment history are identified and discussed at the point of interview. Candidates interview notes are maintained in the file. The only area identified as requiring strengthening was that verbal contact is made to verify and validate the content of at least one of the references given. The provider needs to ensure that all Criminal Record Bureau (CRB) checks are renewed at three yearly intervals. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is able to provide clear leadership and works within the organisation policies and procedures. Staff are well supported through supervision, training and management guidance. Processes exist to gain service user’s opinions and involvement with the running of the home. Good attention is given to matters linked to health and safety. Records are available to document risk and any action taken. EVIDENCE: The registered manager of the home has been seconded to support another service run by the provider. In her absence it has been agreed with the Commission that joint application for the registered manager will be considered. The acting manager is making an application at present. She is an Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 23 experienced, capable manager with the appropriate qualification at Registered Manager Award (RMA) level. The acting manager provides good leadership to the staff team and works to ensure that the staff team are appropriately resourced, trained and supported. The staff group communicated there was an open culture with the team and the staff group. The acting manager has a hands on approach and a good overview of the service. The recruitment of staff has been successful and the staff group have welcomed the newer employees. The provider has recently implemented major restructuring of the management levels across the organisation. The external line manager now has more involvement with the overview of the service at an operational level including day-to-day issues that emerge. The acting manager considers the process will be more supportive and responsive to service user’s needs locally. The provider has developed a more robust quality assurance system that will be transparent about the monitoring processes used. This is a new process and it is too early to make comment about the outcomes. Stakeholder questionnaires were circulated by the home in January 2006. The response rate was 100 . The acting manager shared the results and demonstrated how the staff group responded to concerns and implemented improvements as a result of feedback. The process and structures in place to monitor health and safety matters are well implemented. Fire safety is addressed in the policy and records reflected ongoing training. Records correlated with the number of fire drills taking place. The first aid boxes are located in the home and vehicles and theses are replenished as used. Staff are receiving training as part of the induction process and senior staff are attending a two-day training course in First Aid. The domestic installations checks were inspected and were found to be within the timeframe for maintenance. Risk assessments are in place including being monitored and reviewed. Any conflict with meeting needs is discussed within a multi agency approach and resources are targeted to meet specific needs. All accident records are now being kept in service user’s files. The case files now comply with the expectation of the standards linked to records to be kept in respect of each service user. Records were well organised and stored appropriately. Bromwich Road, 180 DS0000018636.V303788.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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 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 Bromwich Road, 180 DS0000018636.V303788.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. 1. Standard YA1 Regulation Requirement Timescale for action 30/09/06 5 The provider must amend (June,2006) service users literature to reflect transparency of fees and any additional on costs for placements. This will ensure that information is line with recent changes to the National Minimum Standard Regulation 5 June 2006. 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 1. YA34 Good Practice Recommendations The recruitment practices should include the provider taking up telephone references. This will support robust recruitment practices. Bromwich Road, 180 DS0000018636.V303788.R01.S.doc Version 5.2 Page 26 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 Bromwich Road, 180 DS0000018636.V303788.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. 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