Inspection on 22/11/06 for 180 Wylds Lane

This inspection was carried out on 22nd November 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

180 Wylds Lane 25/01/06

180 Wylds Lane 14/09/05

180 Wylds Lane 28/10/04

180 Wylds Lane 01/03/04

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, 180 180 Wylds Lane Worcester Worcestershire WR5 1DN Lead Inspector R McGorman Unannounced Inspection 22 November 2006 3:00 nd Wylds Lane, 180 DS0000018705.V305422.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, 180 DS0000018705.V305422.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, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wylds Lane, 180 Address 180 Wylds Lane Worcester Worcestershire WR5 1DN 01905 764276 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 Andrew George Russell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This service is primarily for people with a learning disability, but may also accommodate people with an additional physical disability. 25th January 2006 Date of last inspection Brief Description of the Service: 180 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, 180 DS0000018705.V305422.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. Staff had assisted service users in completing a survey entitled, ‘Have Your Say,’ – which provides information about what they think about the care and support they receive. Written comments were also requested from relatives, and views sought from visitors or professionals at the home during the inspection. The care records of service users were seen, and discussion about the content held with the care manager, Mr Andrew Russell, 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. 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 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 users to do the things they enjoy and to make choices about their daily lives. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 6 A vehicle is provided to enable each service user to be involved in the local community, and to enjoy trips and holidays further away from home. The building and equipment is well maintained and the house is nicely decorated, and is also comfortable and clean. The Organisation is clear about the support, training and development for the staff it employs, and staff confirmed that they have good training opportunities. What has improved since the last inspection? What they could do better: The information produced about the home for service users and their family needs to be updated regularly to ensure that it is always accurate. The information about service users should be detailed, up to date and organised, to ensure that staff have enough information to be able to care for them in an appropriate way. More choice about meals and mealtimes for each service user will be the result of the proposed review of these. A photograph of each service user included with the individual medication records, will help to ensure that the right medication is always given to the right person. Service users will be better protected if training is provided for all staff on the many aspects of abuse. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 7 Fire awareness training and fire drills need to be organised regularly, to ensure that the safety of service users and staff is protected as well as possible. 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, 180 DS0000018705.V305422.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 Wylds Lane, 180 DS0000018705.V305422.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The information provided for prospective service users helps them to make decisions about their future care needs. The assessment process is detailed and thorough to ensure that the appropriate care can be provided. EVIDENCE: The Statement of Purpose and the Service Users Guide, provide detailed information for service users and their families, about the services and facilities available at the home. The documentation is produced in an appropriate format, and retained by the service user, if this is their wish. Documentation is currently being reviewed, following a recent admission to the home, to ensure that it accurately reflects the specific aspects of the care that can be provided. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 10 The admission procedure includes extensive assessment of a prospective service user by staff from the home, and a Community Care Assessment is also undertaken by the social worker. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 11 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 identifies their assessed needs, and how these will be met, although to do this all care plans need to be fully completed. Service users living at the home are supported by their key workers 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. 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 very detailed with one exception. The care plan of one service user is still being Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 12 developed, and needs to contain further information relating to specific needs, and how these will be met. The person centred approach to care planning is also being implemented, and the participation of each service user in making decisions about their daily life in the home is encouraged by staff. Service users each have two key workers, who have responsibility for ensuring that their needs are met in the way they want, and this also helps with their care. Monthly meetings are held with service users, and any changes are monitored over a period of time and amendments recorded as necessary. The special communication needs of service users are identified, and understood by staff. Everyone living at the home understands the spoken word, although they have some difficulties at times with speaking. Objects of reference are used and one service user is able to use sign language. 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. One member of staff has responsibility for ensuring that risk assessments are in place and that they are updated regularly. Confirmation that reviews are held regularly was found in the care plans. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 13 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. 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, and this 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. The health and wellbeing of service users is helped by the provision of a nutritious and wholesome diet. A planned review of the arrangements should mean greater flexibility and choice for them. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 14 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. Each service user has an Activity Planner that assists them in organizing the various things that they like to be involved in. These may be undertaken at home or out in the community and include shopping, swimming, ten-pin bowling, horse riding, music sessions, cookery, hydrotherapy, attending the film club and going to discos, and going to a pub for lunch or a café for coffee and cake. One service user attends a local day centre, and is also involved in a recycling project. Holiday destinations this year have included Minehead and Abington, and one resident went to see Glen Campbell at the Symphony Hall. Service users are involved with the selection of new staff, and are also encouraged to attend Forum meetings. These are arranged by Dimensions to involve service users in the development of the service. 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. The following comments were received from families about the service: • I cannot praise the staff enough for the way the resident is looked after • Staff are all so professional in what they do • The key workers are appreciated for all their hard work and support • The atmosphere is just like a family home • The carers deserve a medal • No-one in the country is looked after better • These people are beyond price General food stocks for the home are purchased each week with the involvement of service users. The arrangements for the provision food reflect the individual likes and dislikes of each service user, although the menu and the times of serving meals is usually a communal arrangement. Proposals have been made to introduce a more individual approach to preparing, planning and also to the timing of meals, and these are being discussed at present. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 15 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. EVIDENCE: The personal care needs of service users are identified, and there is evidence to show how staff understand and respond to them in an appropriate way. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 16 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. Routine eye care and dental treatment is arranged. One service user who requires chiropody treatment frequently, finds the experience very daunting, but staff were able to explain how the situation is managed in a sensitive way. Service users are protected by the detailed procedures for the administration of medication which are followed at the home: • A Monitored Dosage System is in use, and visits to the home by the pharmacist are undertaken every three months. • The medication prescribed for service users is reviewed regularly by their GP. • The Medication Administration Record charts were checked and had been completed appropriately. • A colour coding system is used as a further precaution against errors being made • A key holder list is signed by the staff member responsible for the administration of medication on each shift. • Detailed procedures are listed which cover the following: giving ‘as required’ medicines, refusal, homely remedies, disposal and medicines that need to be taken out of the home. • A detailed profile was completed for each service user. • Medication training was provided for staff in October. The care manager was advised that a photograph of the service user should also be included with the Medication Administration Records. The care records of a service user contained information about the reasons for requesting a review of the prescribed medication, which started as a moving and handling issue and related to an inability of the service user to weight bear at times. The review resulted in the dose being reduced, the service user has since appeared less tired and is now more active, and his quality of life has greatly improved. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 17 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. All staff need to undertake the training that is provided to ensure that service users are protected from abuse. EVIDENCE: A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately, although there have been no complaints made to the home since the last inspection. The document has been produced in a format that is understandable to service users. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults, and some staff have attended training. Those spoken to were able to demonstrate a clear understanding of the issues, and also to their individual role as an advocate for service users. The need for specific training for some staff was identified, to ensure that service users are protected from abuse. Wylds Lane, 180 DS0000018705.V305422.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): 24,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of service users. The house is comfortable and well maintained, and the equipment provided enables service users to maintain a good level of independence. The premises are clean and hygienic, and ensure as far as possible that the wellbeing of service users is promoted. EVIDENCE: The premises at 180, Wylds Lane is a large detached, purpose built bungalow, which is maintained to a satisfactory standard, and is suitable for its purpose. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 19 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 recently developed sensory room providing a peaceful and relaxing environment, away from the hustle and bustle of the home. The gardens are well maintained, and provide a suitable area for service users during the warmer weather. There is also a patio that can be accessed through a French window from the lounge. There have been several developments recently that have resulted in improvements in facilities for service users. Items of equipment have been repaired or replaced, including the computer, the call bell in the wet room, the extractor in the kitchen, and a grab rail to assist a service user to be more independent in his room. Carpets throughout the home have been cleaned and a new one fitted in one of the bedrooms. Redecoration of the kitchen and a bedroom has been undertaken, and new curtains provided in one of the bedrooms. The home had been advised previously to request an assessment of the premises by an occupational therapist to ensure that service users have the specialist equipment they need to maximise their independence. Following this consultation advice was provided about specific aids, to enable staff to more effectively assist a service user with moving and handling. Additional tracking also been fitted to a bedroom and bathroom, which has further improved facilities for service users. The home is clean and fresh and procedures are in place in regard to the control of infection. There are no outstanding requirements following the most recent visit of the Environmental Health Officer. Wylds Lane, 180 DS0000018705.V305422.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): 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 able to provide appropriate care and support to service users. 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 Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 21 policies and procedures, and an Induction Checklist covering the first three months of employment. Service users 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. A training programme is in place at the home that enables staff to meet the changing needs of service users, and includes Induction and Foundation training, (known as ‘Welcome to Our Team’), the Learning Disability Award Framework (LDAF) accredited training, and the NVQ training. One member of staff recently achieved the NVQ Level 3 in Promoting Independence. The training needs of staff are regularly reviewed, and a training record is maintained in respect of each member of staff. The manager was able to confirm the care related courses that have recently been attended by many staff from the home, which include: Communication, Listening and Enabling, Quality and Outcomes, Eating and Drinking Skills, Abuse Awareness, Risk Assessment, Person Centred Planning and Medication. Wylds Lane, 180 DS0000018705.V305422.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 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 are promoted and protected by safe working practices, although safety may be compromised if fire awareness training is not undertaken with the required frequency. Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 23 EVIDENCE: The care manager Mr Andrew Russell has many years experience working with this client group, and he has been managing 180 Wylds Lane for the last 12 months. He has good communication skills, and has a clear understanding of the role, and his responsibilities. He is undertaking the Registered Managers Award, and continues to update his 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. A comprehensive health and safety policy and procedure is in place, and staff are trained in safe working practices. 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. Contracts are in place for the routine maintenance servicing of equipment at the home, which is all now in good working order. The records checked during the inspection have been completed to a satisfactory standard, and they are securely kept. The accident records were seen to be in order. Notifications are made under Regulation 37, which requires reports to be sent to the Commission of death, illness or other events in the home. Regulation 26 reports, which relate to visits made to the home by or on behalf of the registered provider, are also submitted on a regular basis. The Fire Log Book was seen, and appropriate checks undertaken with the required frequency. Fire awareness training is arranged, although the manager was reminded this should be every three months. In addition a fire drill should Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 24 be organised every six months and a full evacuation undertaken annually, to protect the safety of service users and staff. Wylds Lane, 180 DS0000018705.V305422.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 Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Wylds Lane, 180 DS0000018705.V305422.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 YA6 Regulation 15 Requirement A detailed plan of care must be maintained for each service user to provide clear guidance to staff on the actions to be taken to meet their changing personal and healthcare needs. Training must be provided for all staff on abuse and the protection of vulnerable adults Arrangements must be made for staff to receive fire awareness training, at least every 3 months, and fire drills and practices at suitable intervals – at least every six months to comply with the Regulatory Reform (Fire Safety) Order 2005 Timescale for action 31/12/06 2 3 YA23 YA42 13 23 31/12/06 31/12/06 Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 27 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 YA1 YA17 YA20 Good Practice Recommendations The review of the statement of purpose and the service users guide should be completed without delay A review of the arrangements for the provision of food should be completed and the proposals implemented A photograph of the service user should be provided with the Medication Administration Records Wylds Lane, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 28 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, 180 DS0000018705.V305422.R01.S.doc Version 5.2 Page 29 - 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!