Inspection on 20/06/06 for 182 Ashby Road,

This inspection was carried out on 20th June 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

182 Ashby Road, 12/10/07

182 Ashby Road, 07/02/06

182 Ashby Road, 12/03/05

182 Ashby Road, 23/09/04

182 Ashby Road, 20/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 182 Ashby Road, Burton On Trent Staffordshire DE15 0LB Lead Inspector Ms Wendy Jones Key Unannounced Inspection 20 June 2006 10:30 182 Ashby Road, DS0000004910.V298874.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 182 Ashby Road, DS0000004910.V298874.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. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 182 Ashby Road, Address Burton On Trent Staffordshire DE15 0LB 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) 01283 546260 Robinia Care Homes (2) Limited Wendy Ann White Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user between the ages of 16 & 18 years This particular category to cease on the 18th birthday of the young person identified, which is the 28 February 2004 7th February 2006 Date of last inspection Brief Description of the Service: Number 182 Ashby Rd is registered for five younger adults with a learning disability. The building is a large period semi-detached house located in a residential area, on the outskirts of Burton upon Trent. The other half of the semi-detached property is owned by this company and registered separately. The home is conveniently situated close to a town, on a bus route and close to shops and all amenities. The house is set back from the main road and has limited parking space. The building is on three floors and comprises; five bedrooms, an office/sleeping-in room, lounge, dining/activity room, kitchen, one bathroom and one shower room, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a large garden at the rear and a useful patio area. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of 182 Ashby Road a residential care home, for younger adults with Learning Disabilities, the inspection took place on the 20th June 2006 between 13.00pm and 18.20pm, a follow up visits took place on 26 June 2006. The inspection methodology included pre inspection information; service user, and relative questionnaires, discussion with social workers and feedback in questionnaires; discussion with service users, interviews of two staff; inspection of care records and other documents pertinent to the inspection process; observation and involvement in a staff meeting. There have been some changes since the last inspection, the Responsible Individual has changed to Mr David Pointer and the previous care manager has been promoted to area manager for the organisation. What the service does well: Requirements from the last inspection have been met within the timescales agreed. All service users were in the home at various points throughout the inspection, and all made a contribution towards the inspection process, by completing questionnaires and through discussion on the day. Comments in the questionnaires included “am happy to live here”, “I know who to talk to if I’m unhappy”, “ I am happy here most of the time”, “ I can do what I want to most of the time”, “ 1 would like staff to speak slower so I can understand them better”, “staff treat me well, and usually listen and act on what I say”. Two relative questionnaires were returned, 1 relative expressed satisfaction with the home, stating, “ I have been very impressed with the professional way the home is run and the progress they have made with my relative”. A 2nd relative indicated satisfaction with the overall care, but would like more contact and consultation about their relatives, day to day timetable and to be informed of any changes to medication were prescribed and the reasons for the change. Also stated “ not aware of the complaints procedure, has no access to inspection reports and did not think there was always enough staff on duty”. 4 social work questionnaires were received, 3 expressed satisfaction with the home comments included “ 1 have always been satisfied with the level of support provided and the sharing of information when relevant and necessary”, “an excellent placement for my client”, “ the home communicates well and works in partnership with the social worker, and demonstrates a clear understanding of the care needs of the service user. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 6 Since the last inspection there have been 7 incident reports made under Regulation 37, on each occasion the manager has demonstrated that she has taken appropriate action in the best interests of the service users. 182 Ashby road feedback from social worker. What has improved since the last inspection? What they could do better: Ensure that service users are familiar with the service user guide and have easy access to the complaints procedure and inspection reports from the CSCI. Feedback from some professionals raised issues relating to the care of service users. Comments included the views of a health worker who stated that staff did not follow care plans consistently. One social worker questionnaire stated” staff do not have a clear understanding of the care needs of a service user” and indicated that there had been some conflict of opinion between the social worker and staff. From a telephone conversation held with the social worker, it was recommended that an independent advocate was involved to support the service user with any decision-making. These matters were discussed during the visit, at the feedback session for the manager and with service users. Training issues were identified by the manager and during the inspection and although there is a plan in place. Some training was outstanding including Vulnerable adults and abuse training. The numbers of NVQ trained staff should be improved. A review of the procedures for managing medication must be undertaken to remove or properly manage medication that is decanted from it’s original container. A procedure for making a complaint must be available to relatives or representatives on request. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 7 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. 182 Ashby Road, DS0000004910.V298874.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 182 Ashby Road, DS0000004910.V298874.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): 1,2, 3 and 5 The quality outcome in this area is good. Service users are fully assessed prior to admission to the home to ensure their needs can be met by the service. A Statement of Purpose and Service User guide have been developed in accordance with the requirements of regulation. EVIDENCE: A copy of the Statement of Purpose had been sent to the CSCI, since the previous inspection but it was understood that it was again under review to reflect recent changes. Following discussion with staff and service users it was recommended that further efforts are made to ensure that the Statement of Purpose is made more easily available. Each of the service users personal files contained a copy of the Service User Guide. The document had been produced in a user-friendly format that included simple language and pictures, the content complied with the requirements of regulation and all service users had signed their guide. From discussion with all service users, 1 knew what the Service User Guide was and what it was for, others were not sure. The manager confirmed that while service users may not recognise the service user guide, the aims and objectives and care philosophy are discussed daily. One care file was examined; it contained an explicit assessment of the individuals needs, accompanying assessment and care planning from the funding authority. Fees agreed at the time of assessment and admission were 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 10 included in the information seen. The fee range for the home was included in the pre inspection information as between £78,000 to £98,000 per year. The information in the care file showed how these costs were broken down; there were also contracts between the funding authority and the organisation and a contract between the organisation and individual. 182 Ashby Road, DS0000004910.V298874.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): 6-10. The quality outcome of this area was good. This judgement was based upon the records seen and information provided during this visit. Care plans were in place reflecting the assessed needs of service users, service users stated that they were involved with their care planning and decisions making. EVIDENCE: Since the last inspection the organisation has introduced a new format for care plans linked to valuing people guidance and following the model of Person Centred Planning. A Personal Service plan includes a detailed account of the care needs, plans, aims and objectives and evidence of progress for each service user. Monthly reviews were recorded and additional 1:1 meetings took place to ensure service users were involved with and took a lead role in planning their care and working towards achieving their stated aims. More formal reviews took place, when service users were encouraged to invite relevant people and be involved in setting the agenda. From discussion with one service user it was evident that he was supported by the home to do this. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 12 The manager at the home has consistently demonstrated a willingness to support service users to move to more independence and has worked closely with individuals and their supporters to devise risk assessments that reflect a responsible approach to risk taking. Feedback from service users’ questionnaires indicated that they were usually supported to make their own decisions and staff encouraged them to take an active role in the house. This was evident from the visit, where service users took a lead role for parts of the inspection. Individual service user had differing needs relating to the management of their money. 3 service users had their own bank accounts, 1 service user was supported by his family. All service users received their personal allowances. None of the service users was subject to power of attorney of Guardianship orders. Confidentiality of information had been discussed with each service user and they had made decisions about where to store their care plans. One had chosen to keep his information in his room others had decided to store the information in the office. It had also been agreed that service user access to the office would be limited at times during the day, for example at times of staff handover, or when staff were discussing individual information. Following discussion with one service user it was clear that the reasons for this action were known and understood. 182 Ashby Road, DS0000004910.V298874.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, 14, 15, 16 and 17. The quality outcome in this area was good. This judgement was based upon information provided and from the visit. Service users were supported to be independent within the home and were encouraged to make decisions regarding their daily lives. EVIDENCE: Service users have varied interests; one has a voluntary job, which he hoped would result in paid employment. Other service users had access to community facilities during their planned independent time or with support from staff. This time was agreed as a part of a risk assessment. There were plans to access college placements from September 2006 for some individuals. Recreational activities, including access to swimming sessions, a youth club, bowling and the cinema, bicycle rides, train spotting and shopping were enjoyed by service users. Service users discussed how they were involved in arranging holidays. Two had been away for 4 days; two others had arranged a holiday for the summer. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 14 The organisation has policies in place about staff costs when out in the community with service users, it provides, an amount towards the costs of a meal and drink out of the petty cash system. Information in the care records and from discussion with staff and service users showed that where appropriate contact with families and friends was maintained. The records showed that service users rights to engage in intimate relationships were supported. Relevant advice was sought and given to ensure that there was informed decision making and understanding of safe sex. Service users explained their involvement in the household routines. They described how they were provided with an individual budget for food and supported to plan a shopping list based upon their individual meal plans for the week. Each service user is allocated £40 per week towards the food budget, half of which is pooled towards food basics and essentials and also funds a weekly takeaway meal and the Sunday lunch. The other money is used to purchase the individual foodstuffs each service user has decided they want for the week. Agreements have been reached between service users in relation to storage of food, to ensure that there is no accidental use of foods purchased by someone else. Meal plans showed that service users were choosing their own menus and often four different meals would be prepared and cooked in the evening. Service users also stated that they took a role in monitoring the fridge/freezer temperatures of their fridges and one service user stated he had undertaken basic food hygiene training. Mealtimes were flexible, dependent on the planned activities of service users, on the day of the inspection individuals were choosing to take their meals at different times. 182 Ashby Road, DS0000004910.V298874.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. The quality outcome for this area is good. This judgement is based upon the records and information provided and a visit to the home. The personal and health care needs of service users were met, with evidence of regular reviews. EVIDENCE: Records showed that service users had attended routine health appointments such as dental and optician. GP appointments were also evident in the records available, it was reported that some service uses needed support others were relatively independent. Sexual health issues had been discussed with individuals and appropriate advice sought. Health records included personal medical information, consent to treatment. The organisation has a contract with a psychology service, the level of support for individuals is determined at the start of the placement and following regular review. All service users were accessing this service at the time of the visit. Other specialist health input includes, speech and language therapy, community Learning Disability and psychiatric nurse support. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 16 Pre inspection information received from a health professional raised questions about the services compliance with advice. These matters were discussed during the visit and at the feedback session with the manager. Since the last inspection 3 medication errors had been reported to the CSCI, on each occasion the service had taken immediate and appropriate action to address the problems. Including a change in policy. Staff had been reminded of their responsibilities, additional training had been provided. The training offered included certificated medication training and an in house assessment of competence. The deputy manager identified that some senior staff had been nominated for advanced medication training. A review of the medication administration procedures was also underway to reduce the risk of error further. Medication administration records and records of received and disposed medication were appropriately maintained and medication storage was satisfactory. Medication stocks were sufficient and there was evidence of good standards of stock control. None of the current service user taking medication self medicate oral medication, some have taken responsibility for topical treatments, i.e. creams and ointments. There was evidence in the medication file of records relating to medication no longer prescribed. This information should be removed from the file to avoid confusion. One relative had indicated that they wished to be kept informed of any changes of medication, the purpose of the medication and the reasons why any change had occurred. During discussion about the arrangements for managing service users medication when away from the home, the issue of secondary dispensing was raised. This means when medication from the original container is put into another container, to take on holiday, home visits or day’s out. The advice from the CSCI pharmacy inspector relating to this issue is. For planned events, the service must approach the community pharmacist for the required supply to be dispensed in a suitable container. For unplanned events the service must ensure that there procedures include the action staff must take to reduce the risk of error. It was recommended that the procedure includes two trained staff to check the medication records against the medication doses and quantity provided and both should sign the records. A generic homely remedies list was available in the medication file, there was no indication that it had been agreed with a GP. It was recommended that if there was a need for homely remedies, the medication should be agreed with the GP for each individual. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 17 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The outcome for this area is adequate. This judgement is based upon information provided and a visit to the home. The impression was of a service that offers service users protection while enabling them to take risks. Complaints were viewed as useful and could be used to improve the service delivery. EVIDENCE: Information in the pre inspection records indicates that the service has received 10 complaints in the 12 months prior to the inspection, and that all were substantiated and responded to inline with the complaints policy. A copy of the complaints procedure was included in the service user guide in a form that was user friendly. Service users indicated in the pre inspection questionnaire and during the inspection that they knew who to go to if they had any concerns, 3 service users had independent advocates to support them if necessary. In the pre inspection information a relative stated that they were not aware of the procedure for making complaints. One adult protection strategy meeting has occurred and has been resolved, with the service demonstrating that Vulnerable Adults Procedures are known and followed for the best interest of service users. Training records show that most staff have received training in the protection of vulnerable adults, others have training planned. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 30. The quality outcome of this standard is good. This judgement was based upon information provided and a visit to the home. The environment within this home was well maintained, providing service users with an attractive, clean and homely place to live. EVIDENCE: This inspection did not include a detailed environmental inspection. The home provides ordinary living in a semi detached two storey property in a residential area of Burton-on-Trent. The front drive provides parking for up to two vehicles. A recent programme of decoration has almost been completed and most areas were very well maintained. Service users stated that the kitchen would benefit from repainting. The home was clean and warm. Service user have access to all areas of the home, although there have been restrictions agreed with them about accessing the office at certain times. This decision was intended to protect the privacy of individuals and confidentiality of information. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 20 Each service user has their own bedroom, none are en-suite, a recommendation of previous inspections has suggested that the service would benefit from a second floor toilet. One service user asked that a house number could be fitted near to the front entrance of the home. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 The outcome for this standard is adequate. This judgement is based upon the information provided and a visit to the home. Staffing numbers were adequate. Staff training could improve. EVIDENCE: A change to the staff allocation had taken place since the last inspection, the numbers of staff deployed include 2 from 8am to 10am, and 3 throughout the waking day up to 10pm, 1 waking and 1 sleep in night staff. Some service users received additional funding for 1:1 staffing to provide support with independent living, social, recreational and occupational opportunities. Staff vacancies were recorded as 1 team leader and two support staff, staffing levels were being maintained. Staff vacancies included 2 team leader positions. Service users were allocated a key worker, and knew whom their key worker was. There was evidence of good relationships between service user and staff. Records of training showed that there were some gaps in the mandatory training of some staff, although information during the inspection indicated that additional training and updates had been planned. Training that had taken place since the last inspection included Epilepsy and Autism, the organisation was reported to be changing it’s training provider for proactive behaviour management, the TEAM Teach model was in the process of being introduce across the service. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 22 Computer and Information technology training should be provided for staff. Information in the pre inspection questionnaire received 10 May 2006 stated that 60 of the staff team had achieved NVQ level 2 or above, however since that time a number of staff changes have occurred and one staff has been dismissed. Staff meetings were arranged regularly and during the inspection a health and safety meeting took place. Staff had been allocated responsibility for a particular area of health and safety; this was an opportunity for raising staff awareness and providing information on changes or progress. The subjects discussed included, Medication, COSHH, Laundry, Fire, General maintenance, Risk Assessment, Food hygiene, First Aid and training. Service users were involved in the day-to-day health and safety checks undertaken at the home, it was recommended that they should have a presence at the Health and Safety meetings. Pre inspection information indicated that CRB checks had been carried out and received for all staff with one exception, a new support worker had her check sent off for on 17/03/06, but had yet to be received, the manager had discussed concerns about the delays in receipt of CRB checks prior to the inspection visit. POVA checks were routinely carried out. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42. The outcome for this standard is adequate. This judgement was based upon information provided and a visit to the home. The manager is supported well by her senior staff in providing clear leadership throughout the home. Detailed risk assessment and regular monitoring of safety systems promote the health and safety of staff and service users. EVIDENCE: The manager identified in the pre inspection information that she understood her responsibilities to service users, staff, under the Care Homes Regulations 2001 and National Minimum Standards for Younger Adults. She has consistently demonstrated, since her appointment as manager that she has the ability to manage the service. Ms Russell is to be interviewed by the Commission for Social Care Inspection for the position of registered care manager. Pre inspection information indicated that maintenance and servicing of equipment was carried out regularly. Records showed that fire safety matters 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 24 were monitored regularly and staff had been involved in training, fire drills and training. A fire safety risk assessment had been revised in January 2006. Regulation 26 visits were carried out by the area manager and monthly reports forwarded to the CSCI. The format used gave a detailed account of the performance of the home. Policies and procedures required by regulation were in place, a sample of those listed were checked at this visit, information in the pre inspection information indicated that reviews had been undertaken. Although it was recognised that some had not been reviewed for some time for example, Aggression towards staff, Bullying, Emergency and Crisis, Risk assessment and management. Risk assessments were in place for individuals and for general issues. 182 Ashby Road, DS0000004910.V298874.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 3 2 3 3 3 4 X 5 3 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 3 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X 3 3 X 182 Ashby Road, DS0000004910.V298874.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. 2 Standard YA23 YA20 Regulation 13 13 Requirement Staff must receive training in recognising and reporting adult abuse. The registered provider must ensure that the systems for the administration of medication do not place service user at risk. This was in relation to the issue of secondary dispensing. The registered person must ensure that staff have up to date mandatory training and other training relevant to the service user group and aims of the service. The registered person must provide a complaints procedure to representatives/ relatives of service users on request. Timescale for action 07/09/06 07/09/06 3 YA35 18 07/10/06 4 YA22 22(5) 07/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 27 1. 2. 3. 4. 5. 6 7 8 9 10 11 YA27 YA33 YA6 YA13 YA13 YA24 YA40 YA42 YA35 YA32 YA20 Give consideration to the provision of toilet facilities on the ground and second floor. The service should make further efforts to recruit a full staff team. The service should ensure staff have received the training required in implementing the new care planning paperwork. Consider the impact the lack of drivers has on the community presence of service users, and review. Agree homely remedy lists with the GP for each service user. Consider fitting the house number to the front of the home as suggested by a service user. The policies and procedures in the home should be kept under regular review. VDU risk assessments should be undertaken for those staff who regularly use the computer. Information technology/computer training should be provided for all staff. NVQ training should be provided for 50 of the care team. Where appropriate and with service user consent, inform relatives of changes to medication. 182 Ashby Road, DS0000004910.V298874.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 182 Ashby Road, DS0000004910.V298874.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!