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Inspection on 19/03/08 for 204 Ashby Road

Also see our care home review for 204 Ashby Road for more information

This inspection was carried out on 19th March 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides information for prospective residents to ensure that they know what the service offers it also ensures that any prospective resident receives an assessment so they can be sure that the service can meet their needs. The service promotes the rights of residents and advocates on their behalf.Residents can be confident that the service has procedures in place to ensure their well being and safety and that any concerns they have will be listened to and addressed. The service records show that the health care needs of residents are known and monitored, where necessary individuals are supported to attend health appointments. Medication records are appropriately maintained. Records of staff training are maintained and the manager can show that outstanding training is planned. Recruitment procedures are robust.

What has improved since the last inspection?

The service has addressed or partially addressed the areas of concern identified at the last inspection and the current manager demonstrated her intention to sustain the current levels of improvement.

What the care home could do better:

Although the service has introduced a new person centred planning model this is yet to be fully implemented and the risk assessments in place should be regularly reviewed to ensure that they are up to date. The individual care records must also include information about behavioural management to ensure that the staff know what they should do when a resident exhibits challenging behaviour. Efforts have been made to increase resident opportunities to access community activities but further work is needed in this area particularly around educational and occupational opportunities. The environment is generally well maintained but the water damaged ceiling needs to be repaired and redecorated and residents should be able to bathe in water that meets the recommended temperature. The service should recruit staff to fill the current 8 staff vacancies and reduce the number of agency staff it uses. The manager must submit her application to be approved to us and undertake the training that is recommended for registered managers. An emergency contingency plan for the service should be produced.

CARE HOME ADULTS 18-65 204 Ashby Road, Burton On Trent Staffordshire DE15 0LA Lead Inspector Wendy Jones Unannounced Inspection 19th March 2008 10:45 204 Ashby Road, DS0000004912.V358513.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 204 Ashby Road, DS0000004912.V358513.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. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 204 Ashby Road, Address Burton On Trent Staffordshire DE15 0LA 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 517020 carol.walton@robinia.co.uk Robinia Care Homes (2) Limited vacant post Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2007 Brief Description of the Service: Number 204 Ashby Rd 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 privately owned. The home is registered to provide accommodation to six adults with a learning disability. The home currently provides care for four adults with severe learning disabilities and complex needs and individuals who have been diagnosed as having needs on the Autistic Spectrum Disorder. The home is conveniently situated near to town centre, on a bus route and close to shops and all amenities. The house is set back from the main road and has tarmac drives and adequate parking space. The building is on four floors (including basement) and comprises six bedrooms, an office, lounge, dining/activity room, kitchen/dining room, art room, two bathrooms each with bath, shower and toilet, two separate toilets, laundry room and storage. The home is not suitable for any person with a severe physical disability. There is a very large garden at the rear and a useful patio area. Suitable outdoor furniture has been provided, including swings. A care manager and a team of support workers provide care. The home has its own multi-seat vehicle, which is available for use by people who use the service. The fees are included in the service user guide and are broken down to ensure that prospective and existing resident know how much the service costs. The fee range is up to £112,792 per year. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was a 2nd key inspection site visit of this service undertaken on 19 March 2008 and included formal feedback to manager. In total the visit took approximately 6:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 04/07/07 have been acted upon; looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, staff and residents were spoken to during the site visit, observations were made of interactions and care practice and a brief tour of the building was undertaken. As this was the 2nd key inspection visit, in the year 2007-2008, the service was not required to complete an Annual Quality Assurance Assessment (AQAA). The new manager has worked hard to address all the issues identified at the last key inspection, but some areas have yet to be worked on and completed. Since the inspection the manager has confirmed that action has been taken to ensure that all requirements and recommendations from this report have or will be acted upon within the timescales stated. What the service does well: The service provides information for prospective residents to ensure that they know what the service offers it also ensures that any prospective resident receives an assessment so they can be sure that the service can meet their needs. The service promotes the rights of residents and advocates on their behalf. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 6 Residents can be confident that the service has procedures in place to ensure their well being and safety and that any concerns they have will be listened to and addressed. The service records show that the health care needs of residents are known and monitored, where necessary individuals are supported to attend health appointments. Medication records are appropriately maintained. Records of staff training are maintained and the manager can show that outstanding training is planned. Recruitment procedures are robust. What has improved since the last inspection? What they could do better: Although the service has introduced a new person centred planning model this is yet to be fully implemented and the risk assessments in place should be regularly reviewed to ensure that they are up to date. The individual care records must also include information about behavioural management to ensure that the staff know what they should do when a resident exhibits challenging behaviour. Efforts have been made to increase resident opportunities to access community activities but further work is needed in this area particularly around educational and occupational opportunities. The environment is generally well maintained but the water damaged ceiling needs to be repaired and redecorated and residents should be able to bathe in water that meets the recommended temperature. The service should recruit staff to fill the current 8 staff vacancies and reduce the number of agency staff it uses. The manager must submit her application to be approved to us and undertake the training that is recommended for registered managers. An emergency contingency plan for the service should be produced. 204 Ashby Road, DS0000004912.V358513.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. The summary of this inspection report can be made available in other formats on request. 204 Ashby Road, DS0000004912.V358513.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 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use the service can be sure that they will receive information about the service that tells them what the aims and objectives are, and what they can expect. This ensures that prospective resident and their supporters can make an informed decision about moving in to the home. They can also be sure that they will receive a full assessment prior to moving and admission arrangements will be tailored to meet their needs. EVIDENCE: The service has a Statement of Purpose and Resident guide. These documents are available in the home and each resident has a copy of their guide in the care records. Each guide contains the fees and costs for the service and how these are broken down. Both documents have been reviewed since the last inspection. Each service user has a copy of their contract with the service and the terms and conditions of residency. Records show that one resident has been admitted since the last key inspection it is understood that the pre admission information was assessed at that time, and found to be satisfactory. The admission procedures for the home are robust and where possible included introductory visits to the home. Assessments from other professionals such as social workers are kept on each resident file. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 10 During this visit the imminent transfer of one resident and the homes discharge policy was discussed. 204 Ashby Road, DS0000004912.V358513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they have a care plan in place, but these have not yet been fully implemented, although there is evidence that they and their families are involved in this process. Risk assessments are now more person centred but people cannot always be sure that they have been reviewed nor can they be sure that staff have the information they need to support them if they present behaviour that is challenging, This potentially places them at risk. EVIDENCE: Since the last key inspection and random inspection, the service has introduced a new person centred planning format. A sample of the documentation shows that this model meets the requirements of a truly person centred approach to care. The support plans are based upon the known assessed needs of the individual. There is evidence that families and 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 12 supporters of the individual have been involved in the process where a resident may not have the capacity to fully understand their plans. Resident capacity to consent is an area that the service is working hard to establish, the manager has completed some training and is keen to ensure that resident are consulted and involved with all aspects of their care and decisions about their lifestyle. At the time of this visit the new model of care planning was in the process of being introduced and as yet has not been fully implemented, the manager discussed her vision for the system and the benefits and improved outcomes for residents. Risk assessments for all individuals have been reviewed since the last key. There are general risk assessments that apply to all residents and specific risk assessments for the individual. Most risk assessments have been reviewed regularly but in a sample some review dates had been missed this was discussed with the manager who agreed to ensure that these reviews are undertaken. Behavioural management strategies are devised in conjunction with a psychology service, which the organisation has a contract with. At the last inspection there were concerns about some of the advice and strategies being implemented. The manager confirmed that immediate action had been taken at that time to ensure that individual’s rights were not being compromised. But it is disappointing to note that behavioural management strategies for individuals are not properly recorded. This means that staff do not have the information in the care records they may need to support a resident if their behaviour presents a challenge. The manager agreed to address this. 204 Ashby Road, DS0000004912.V358513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service are given the opportunity to take part in a small range of activities both within the home and in the community. But there have been efforts to increase the variety and frequency of these opportunities, which means that residents’ social, recreational, educational and occupational needs are partially met. EVIDENCE: Serious concerns were identified at the last key inspection regarding some decision making about the community presence of one resident and a plan had been devised that restricted her community activity. The manager confirmed that there was an immediate removal of any such restrictions following the last key visit. The activity records of 2 individuals show that on average residents have a community outing 4 times per week. There continue to be limitations on individuals’ accessing educational or occupational opportunities. The manager 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 14 stated that despite efforts no suitable event has been found. But she intends to continue to pursue this matter. An activities co-ordinators has been recruited recently and is in the process of pre planning activities. It is intended that residents will have a pictorial reference system to ensure that they know what the planned activities for the day are and to assist them to make an informed decision about participating in them. During this visit residents went out to day services, one went out for lunch, and another went out on a community activity. One resident was engaged in activities of their own choice, others were participated in passive activities such as watching TV or listening to music. 50 of the care team on the day of this visit were agency staff. 204 Ashby Road, DS0000004912.V358513.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use services have access to health care services both within the home and in the local community. Health needs are monitored and appropriate action and intervention taken. The home also has robust systems in place to ensure suitable medication systems and practices are in place. This ensures that individuals know that their health and medication needs can be met. EVIDENCE: In the sample of care records seen there is evidence that the service has made every effort to liaise with health professionals regarding the healthcare needs of residents. There is evidence of consultation and regular appointments and involvement of health professionals included, community nurses, GP, consultant neurologist, psychiatrist and psychologist. The organisation purchases psychological service from the Densy group. Health action plans are in the process of being implemented; from the sample seen, these present very good information about the health needs of residents and what action needs to be taken by the staff team to monitor and meet the 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 16 identified need. Records show that residents health has been properly monitored since the last key visit; this includes weight monitoring and any injury. Further work should be undertaken to ensure that residents are actively involved in their care and that their capacity to consent is sought. Medication: the manager described how she has tried to make changes to the medication procedures to ensure that they are robust. Since the last inspection one medication issue has been reported to us, but has been satisfactorily resolved. The evidence of this visit shows that medication records are appropriately maintained, and an audit trail of medication can be carried out from the point the medication is delivered to the home to the point where any medication is returned to the pharmacy. Protocols are in place for medication that is prescribed on an occasional basis, which provide staff with clear instructions for when the medication is to be administered. Information in the medication files includes descriptions of medication abbreviations and the purpose and effects of any medication prescribed. Records also show that medication reviews have been undertaken. The manager discussed how the service provides support to residents who may have suffered bereavement, by seeking professional assistance and bereavement counselling if appropriate, and supporting residents to attend funerals. Families have been consulted about any arrangements they may prefer in the event of the death of their relative. 204 Ashby Road, DS0000004912.V358513.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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 can be sure that staff know how to respond to any concerns they may have and are trained to recognise and protect them from suspected abuse. This can give them confidence that the service acts in their best interests at all times. EVIDENCE: The service has a complaints procedure; this is displayed in the home and has been produced in a user-friendly format. This information is also included in the Statement of Purpose and resident guide. The manager stated that she had not received any complaints since the last key inspection this was confirmed from the records seen. Records show that staff have received training in recognising and reporting suspected abuse at induction but the manager also stated that separate training and up dates are also provided. It is also noted that the manager has asked staff to read the safeguarding and the whistle blowing policy and sign to indicate they have done so. We have not been advised of any complaints or safeguarding referrals since the last key inspection. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use services are encouraged to personalise their bedrooms to reflect their interests and choice. The bathrooms and toilets are provided in sufficient numbers meet the needs of the people who use the service, though the temperature of the bath was too low. EVIDENCE: This visit did not include a detailed inspection of the environment. It is noted that previous inspections have described the home as a large semi detached property in a residential area of Burton on Trent, located on a busy main road. The home has a main front entrance and a side entrance leads into a small fenced area and provides some security for people who use the service once they leave the home. The accommodation consists of a large entrance hall, with a large lounge, lounge/dining room, kitchen/dining room, toilet and an office on the first floor. There is a large basement, which accommodates a sensory room, an activities 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 19 room, a laundry and a medical room. The first floor is on two levels and provides five bedrooms, all of which were large single rooms, and none had an en-suite. The service has two bathrooms and separate toilets. Observation of the environment shows that it is clean and fairly well maintained although a ceiling on the ground floor shows signs of water damage from a flood and some areas of the service could be better maintained. Efforts to make the service homely have suffered due the balance between doing this and ensuring equipment in the home is secure to avoid damage. A sample of two bedrooms shows that residents are supported to personalise them where possible, again this is determined by the individuals’ own choice. Checks of water temperature and the records show that they are maintained at between 37 and 39 degrees, this was raised as an issues at the last key inspection and discussed again during this one. Health and Safety guidance indicates that recommended hot water temperatures in areas where full body emersion occurs should be between 41 and 45 degrees to provide people with bath water that is at sufficient temperature to provide a pleasant bathing experience. The manager stated that the organisations policy states that the water temperature should be at 39 degrees. It is suggested that this temperature is too cool and should be reviewed. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the service has good recruitment procedures and the staff team is supported through a comprehensive induction and training programme. But staff vacancies have resulted in the high use of agency staff; this could potentially affect continuity of care. EVIDENCE: The manager discussed changes to the staffing numbers since the last key inspection numbers are now maintained at 4 throughout the waking day and 2 staff at night. Staffing and recruitment difficulties have resulted in the high use of agency staff, an example was evident on the day of this visit. The manager stated that she had 7 full time vacancies and 1 part time. It was reported that 3 staff have left since the last key inspection visit. 2 of the staff on the morning shift were from an agency. The manager said that she has made arrangements with the agency to have the same staff allocated; this offers consistency that is particularly important for the resident group. One agency staff confirmed that he had completed a number of shifts at the home, he stated that he had received a satisfactory induction and had been provided with relevant information required to ensure that he was 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 21 equipped to meet the needs of the resident at the home. He also stated that the staff team had provided a supportive environment. Another member of staff commented that things have been difficult because of the staffing situation but appear to becoming more settled. The manager was interviewing for new staff during this visit. The manager has developed a training matrix that she updates to ensure that it accurately reflects the current training and training needs of the staff team. It shows good levels of training and where gaps have been identified up dates or training sessions have been planned. Supervision information shows that most of the staff have received two, one to one staff supervision sessions this year. A sample of 2 recruitment records show that the service has robust recruitment procedures with evidence of pre employment checks and references. Each file also has copies of a staff contract. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the systems in the home ensure that equipment is well maintained, regularly checked and serviced, and the service continues to try to improve its standards. But they need to be confident that the service can sustain the improvements and has a manager that is approved and has the qualification for the role she undertakes. EVIDENCE: The manager of the service has been appointed since the last key inspection and as yet has not been approved by us or has the qualifications recommended. She discussed her application and plans to start on the registered care managers’ award training course in April of this year and provided evidence of her enrolment on the course. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 23 Records of the monthly visits to the home by a representative of the organisation are available in the home, these reports show how well the service is performing and are used to inform the annual quality audit of the home. The manager also provided evidence that the service has sent out questionnaires and surveys to residents, their families and other interested parties. The results of the information and the outcome of our key inspection visits help to determine the following years annual development. Records show that equipment in the home is checked and serviced regularly, this includes, fire safety and electrical. The manager undertakes quarterly health and safety audits as part of the service and organisations quality monitoring arrangements. In addition daily maintenance and hot water temperature checks are carried out. As discussed in the environment section of this report the hot water temperatures continue to be set too low and should be reviewed for the residents’ benefit and comfort. Fire safety risk assessments have been completed for the environment generally and have been included for individuals. But it is recommended that an emergency contingency plan be developed so that staff know what they need to do if the home has to be evacuated. 204 Ashby Road, DS0000004912.V358513.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 4 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 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 2 2 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 3 2 x 3 x x 2 x 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 25 Yes 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 YA37 Regulation 9 Requirement The manager must submit an application to us to be considered for approval as the registered care manager. To continue to explore options for development of skills and educational activities in consultation with people who use the service or their representative, in order that suitable activities are provided. Timescale for action 19/06/08 2. YA12 12(1)(b) 30/08/08 3. YA6 15 4. YA27 YA42 23(2)(j) Staff must have the 26/04/08 information they need to enable them to support residents when they exhibit challenging behaviour. The hot water temperature in 19/04/08 the bathrooms needs to be maintained at a suitable level. (Previous timescale not met) The provider must recruit staff in sufficient numbers to reduce the current high use of agency staff. 19/05/08 5. YA33 18 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 26 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. 4. Refer to Standard YA6 YA9 YA24 YA42 Good Practice Recommendations The service should make further efforts to fully implement a person centred approach to care. Risk assessments should be reviewed regularly and with in the services own identified timescales. Repairs to the environment should be undertaken promptly this relates to the water-damaged ceiling. The manager should devise an emergency contingency plan for the service. 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 204 Ashby Road, DS0000004912.V358513.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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