Inspection on 19/03/08 for 47-49 All Saints Road

This inspection was carried out on 19th March 2008.

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

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

Other inspections for this house

47-49 All Saints Road 18/09/08

47-49 All Saints Road 01/12/06

47-49 All Saints Road 20/03/06

47-49 All Saints Road 28/07/05

47-49 All Saints Road 11/03/05

47-49 All Saints Road 13/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 All Saints Road, 47-49 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ Lead Inspector Gillian Goldfinch Unannounced Inspection 19th March 2008 2:30 All Saints Road, 47-49 DS0000061835.V355644.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 All Saints Road, 47-49 DS0000061835.V355644.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. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service All Saints Road, 47-49 Address 47-49 All Saints Road Bromsgrove Worcestershire B61 0AQ 01527 579520 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) Worcestershire Mental Health Partnership NHS Trust Mrs Amanda Deborah Jeffries Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (2) All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2006 Brief Description of the Service: 47-49 All Saints Road is a traditional two storey detached house in a residential street within a mile of Bromsgrove town centre. Each of the service users has their own bedroom, individually decorated and furnished, with a shared lounge, dining area and kitchen. Local shops, public transport, the Mental Health Resource Centre and voluntary sector day centres are nearby. The home aims to provide a domestic environment promoting independence and dignity. Those who use the service receive care and support to live as ordinary a life as possible in the community. The registered manager at the home is Amanda Jeffries. She was registered as the manager of the home in January 2005. The registered provider is the Worcestershire Mental Health Partnership NHS Trust. The responsible individual is Ms Ann Bennington. The Trust has been the registered provider since July 2004. Before this date, they were the staffing provider only. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is 0 stars. This means the people who use this service experience poor quality outcomes. This was a full inspection of the home to look at how the home is performing in respect of the core national minimum standards (the report says which these standards are). We call this type of inspection a key inspection. The inspection visit was unannounced and took place over one day. The Home completed an Annual Quality Assurance Assessment before the inspection and the information provided in this was taken into account. The inspection included time spent with the care manager assessing the Home’s progress in meeting the National Minimum Standards and in implementing the requirements that were made as a result of the previous inspection. Time was spent with those who live at the home and some staff. Throughout the inspection, there were opportunities to observe and overhear staff contacts with people who live in the Home. Documentation was checked; including the care records of people who live at All Saint’s Road, and some staff files. Copies of policies and procedures were made available. What the service does well: What has improved since the last inspection? Most of the requirements made at the previous inspection have been implemented. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 6 Improvements have been made to the format used for planning care. This now includes planning for physical health care needs and promoting healthy living. Adjustments have been made to the staff rota to assist in the support given to individuals to access activities in the evening. Quality assurance and monitoring systems have been introduced to provide continuing monitoring, evaluation and review of the service offered. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home operates a thorough admission’s procedure. An appropriate assessment of the needs and aspirations of those who use the service had been carried out. EVIDENCE: Pre-inspection information provided by the home showed there had been no new admissions since April 2006. The registered manager stated that any new referral would include an assessment based on a range of information relating to the prospective service user. This would include information relating to their background, needs and aspirations, likes and dislikes. This information would be gathered from all those involved in supporting the prospective service user. This may include other relevant professionals, family members, previous carers and the individual themselves. As part of the assessment process the home always considers the prospective individual’s compatibility with the existing resident group and only accommodates individual’s whose needs can be met by the service. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 9 Individual’s admitted in 2006 had full assessments of their needs before admission. Samples of care records were checked and ongoing assessments of individual needs were seen, these were being reviewed regularly and translated into care plans. One individual who spoke to the inspector stated they could not remember the detail of their initial assessment but was aware that it took place and had felt included in the process. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service were aware of the contents of their plan of care, encouraged to make decisions about their lives and supported to take risks as part of an ordinary lifestyle. Some improvements are needed to the way in which information on individual care needs is recorded and kept. EVIDENCE: People who lived at the home had an individual plan of care, which identified their specific needs in relation to care and support. Each individual had a named key worker who had some responsibility for ensuring that assessed needs were being met. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 11 Following requirement made at the previous inspection the care plan format had been revised to include the stated aims, aspirations and goals of those who live at the home and details of how the home would support each individual in achieving these. Samples of care records were looked at and showed the requirement to have been met. Examples of individual aspirations included: • • • Applying for and obtaining a passport for the first time Setting up a film night in the home Going out for a meal. There was evidence that identified needs and aspirations were being regularly reviewed. Each month individual’s had the opportunity to review and revise their aims and aspirations with their key- worker. A key worker is a designated member of staff who has some responsibility, under the guidance of the registered manager, to ensure the care needs of specific individuals are being met. Evidence was recorded in the plans of care, which showed individuals were assisted in making decisions about their lives. One individual stated, “The staff here help me to decide the best way to go when I’m not sure. They talk with me and help me look at options”. A six monthly review of care was held for each individual, this provided an opportunity for all those involved in supporting people living at the home to meet with the individual, to review and address any changing needs or aspirations. One health professional who visits the home stated in a survey undertaken by the commission for social care inspection: “The staff team have regular meetings to discuss service users changing needs and the responses required”. Requirements made at the last inspection regarding the regular review of care of those who live at the home, and the involvement of all relevant people in any such review had been met. Some individuals had complex and challenging needs; where appropriate individual risk assessments had been carried out. However, guidance for staff in the management of identified risks was not always clearly stated in the risk assessments. Examples of this were: All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 12 One risk assessment stated “Stabbed self in stomach’. There was no clear written guidance on how staff should manage this situation. This does not ensure the health and safety of the individual. Another individual had been identified at risk from drinking hazardous substances and had made a previous suicide attempt drinking bleach. During a tour of the building a full bottle of bleach was found in a toilet. This does not ensure the health and safety of this individual. It also implies that staff were not mindful of identified risks. An immediate requirement was issued relating to this finding. The matter was discussed with staff on duty and immediate action was taken to secure the bleach. Risk assessment must include the action to be taken by staff to minimise any potential risk. Chemicals which may place people who use the service at risk of harm must be stored safely and secured when left. At the time of the inspection, the plans of care were held on computer. A paper copy was not available for inspection. Risk assessments were also kept on computer but paper copies of these were available. Care records required to be kept at the home must be available for inspection at all times. This was discussed with the registered manager who stated paper copies of all care documents would be produced and kept available for inspection at all times. Individuals were able to read and contribute to their plans of care using the computer. A book was kept for individuals to sign as a record that they had seen their plans. All Saints Road, 47-49 DS0000061835.V355644.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): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who use the service were supported by staff to be involved in a range of educational, occupational and leisure activities. The home helps individuals to stay in touch with their friends and relatives. Individuals were encouraged to participate in the daily running of the home and to develop their social and domestic living skills. EVIDENCE: There was evidence that individuals were able to participate in appropriate activities. Care records showed details of these activities. Some activities were based within the home and others within the community. Individuals attend various educational, occupational and leisure activities on a full or parttime basis. Examples of these include: • Access to community based specialist mental health services DS0000061835.V355644.R01.S.doc Version 5.2 Page 14 All Saints Road, 47-49 • • • • French lessons Attending football matches Going out for meals Attending day care settings All individuals have had an annual holiday with which they were involved in selecting and planning. Following recommendation made at the last inspection changes had been made to the staff rota enabling staff to provide greater assistance for individuals who participate in activities during the evening. This has meant an increased number of staff available on some evening shifts each week. One health professional that visits the home stated in a survey undertaken by the commission for social care inspection: “At the last clinic appointment and review my client reported that he values the activities he is engaged in and the support that he receives”. The registered manager stated that relationships with family and friends of those living at the home are good. Family and friends are welcome to visit, or take individuals out; individual bedrooms can be used for privacy during visits. The home had a telephone that could be used in privacy. One individual told the inspector: “My family and friends visit me here and are welcomed by the staff and other residents”. Individuals who spoke with the inspector confirmed they receive their mail unopened and that they have keys for their bedrooms. All those who live at the home are registered to vote and supported to do so if they wish. The ethos of the home is to support individuals to be as self-caring as they are able. To encourage independence and empowerment according to individual assessed need. The registered manager stated: “Each individual is encouraged and supported to be involved in the daily running of the home”. Staff provided assistance with developing social and domestic skills. Individuals were encouraged to be involved in the care of their living space, cleaning, cooking and laundry. Mealtimes were flexible. Individuals were responsible for getting their own breakfast, assistance and support from staff was provided where necessary. If not at work or attending day care facilities individuals were supported to All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 15 prepare their lunch at home. Individuals took turns to prepare and cook the evening meal and staff cook Sunday lunch. Individual risk assessments were in place for all domestic and catering tasks. During the inspection the kitchen area was seen and was well stocked. There was a good range of fresh vegetables and fruit, frozen foods, a well-stocked fridge and well-stocked dry stores. One individual told us; “I like to cook me dinner, the staff help me, and I think I’m getting better at it”. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff suitably supported the health and personal care needs of those who use the service. The control and administration of medication was being safely managed. EVIDENCE: The personal support, physical and emotional health care needs of individuals was detailed in their plans of care. The registered manager stated on the pre-inspection assessment that within the last twelve months the home had devised a physical health care plan, which was included in the individual care plans. This detailed the personal and emotional support required by each individual. The emphasis of the plan was to assess physical and emotional care needs and to encourage healthy life style issues, e.g. healthy diet, smoking and exercise. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 17 The physical health care needs of those currently living at the home are minimal. Most individuals are able to provide for their own daily physical care although some may require support from staff to ensure tasks are undertaken. Staff who spoke with the inspector were able to describe how any such support is offered in ways that protect the dignity of the individual requiring the support. Plans of care seen during the inspection adequately addressed health care needs and were up to date. Individuals seen at the inspection did not have physical health care needs or did not wish to discuss them. Support is provided for individuals to access community health services such as optician, chiropodist, dentist, and audiologist. Mental health reviews are held as necessary with community mental health professionals. Any such appointments were monitored and recorded. The home had written policies and procedures in place for the administration of medication. Staff were administering a range of medication from prescription drugs to household medication. At the time of the inspection, none of the people living at the home were self-medicating. Staff had received training in the administration and safekeeping of medicines. The inspector observed the administration of medication; this was appropriately and safely carried out. Requirement made at the previous inspection for staff administering nonprescription drugs to complete the appropriate administration of medication record was checked and was being met. The home has access to pharmacy advice via the trust pharmacist. All Saints Road, 47-49 DS0000061835.V355644.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had policies and procedures in place to enable those who use the service or their representatives to raise concerns or complaints. The home had appropriate policies and procedures in place to protect those who use the service from abuse, neglect or self-harm. These were not being fully implemented to protect those identified by the home as being at risk. The registered manager needs to undertake training in the protection of vulnerable adults. EVIDENCE: The home had a suitable policy on responding to concerns and complaints. This included CSCI (Commission for Social Care Inspection) contact details and gave an assurance that any concern would be dealt with within 28 days. There was a record kept of complaints and concerns, and of the action taken in response to them. There had been no complaints received by the home since the previous inspection. Individuals who spoke with the inspector were clear about how to voice any concerns or complaints and to whom they could do so. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 19 An adult protection policy was in place, which reflected local multi-agency vulnerable adult guidelines. No adult protection issues had been reported since the previous inspection. All staff with the exception of the registered manager had received training in the protection of vulnerable adults from abuse or self harm. The registered manager plans to attend a training course in the near future. Requirement made in relation to Standard 9 of this report is also applicable to this section of the report in that it relates to the protection of individuals from self-harm and therefore to Standard 23. When assessing risk, adequate management strategies must be implemented to address any identified risk and to ensure the protection of individuals from possible self-harm. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home are provided with a clean, well-maintained environment which is homely and comfortably furnished. EVIDENCE: The home’s premises are suitable for its stated purpose and provide a homely and comfortable environment. Its location provides easy access to local facilities with access to the bus route into the town centre. The home provides a kitchen, two lounges, individual bedrooms, laundry and sufficient bathrooms and toilets to meet the needs of those who use the service. The communal rooms are comfortable and well furnished and provide adequate space for shared activities and communal living. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 21 People using the service benefit from having access to a private well maintained rear garden. With the exception of issues outlined earlier in this report, relating to hazardous substances not being securely kept, the home complied with health and safety regulations. There was a maintenance book in place so the home can monitor the general upkeep of the building, fixtures and fittings. Individuals who spoke with the inspector were happy with the accommodation, its location and their individual bedrooms. The home was clean and tidy. There were no unpleasant odours or smells. There was a policy and procedure for the control and spread of infection. Not all staff had up to date training in infection control. Information provided by the registered manager prior to the inspection stated three staff were due to have updates to their infection control training. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Those living at the home were supported and cared for by an established and consistent team of staff. Rigorous staff recruitment procedures safeguarded people who use the service. People using the service also benefit from having their needs met by staff who have the knowledge and skills needed to ensure support needs are met. EVIDENCE: Those who use the service benefit from a staff team, which is well established and experienced. Individuals who spoke with the inspector stated that staff were approachable and that they felt comfortable in their company, listened to and supported. The staff team are experienced in the field of mental health and are knowledgeable about the conditions that may affect those living at the home. However, as demonstrated earlier in this report staff had not always taken All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 23 appropriate action to meet the identified needs of individuals in relation to health and safety. Since the previous inspection, the registered manager had adjusted the staff rota to allow a higher staffing level in the evenings to assist individuals to be supported by staff to participate in activities outside of the home. Requirement made at the previous inspection regarding support staff attaining NVQ qualifications had been met. The registered manager stated on the pre inspection assessment that four of the five support workers had attained NVQ level 3, (supporting independence). The registered manager continues to work towards achieving the registered manager’s award and NVQ level 4. The registered manager stated that the staff had received training in health and safety including first aid, infection control and fire safety. Two staff files were selected for inspection. We found that appropriate staff recruitment procedures were in place including written applications, interviews, written references and CRB (Criminal Record Bureau) disclosures and POVA (Protection of Vulnerable Adults) checks secured before staff began working at the home. A photograph of a staff member was not held, this was discussed with the registered manager who confirmed this matter would be addressed. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 24 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): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is working hard to develop a level of service that provides good outcomes for people who live at the home but the absence of effective risk management may result in peoples needs not being met. EVIDENCE: The manager is an experienced practitioner with knowledge and experience of mental illness. She is a qualified registered mental health nurse but has not yet completed the Registered Manager’s Award and NVQ level 4. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 25 People who live at the home, staff and a visiting professional all spoke of the registered manager in a positive way, stating her to be ‘approachable, kind, caring, helpful and fair’. Much work had been undertaken since the previous inspection in developing quality assurance and quality monitoring systems for the home. These are now in place and aim to measure success in achieving the aims, objectives and statement of purpose of the home. These systems include mapping the services provided against the national minimum standards. Seeking feedback with questionnaires from all parties interested in the home including those who use the service their relatives/ friends and other professionals. This is done with written surveys/questionnaires and through verbal feedback. A six monthly service review is now held from which a quality monitoring report is produced. The purpose of the review is to assess progress made during the previous six months in meeting key objectives. Areas covered by the review include staffing, concerns and complaints, health and safety, aims and objectives. Information collated from the review is used as part of a systematic cycle of consultation, planning, action and review. The home has an annual development plan, which forms part of, and is linked to, the quality assurance and monitoring systems. The plan provides a way in which the service is able to identify areas of strength and weakness, create an action plan and monitor improvements based on feedback from consultation or auditing processes. The home’s policies and procedures cover the necessary areas in relation to the health, safety and welfare of residents and staff. Requirement made at the previous inspection for environment risk assessment to be completed had been met. The registered manager aims to ensure safe working practices within the home e.g. fire safety, food hygiene and infection control. Staff had received training in these areas. Fire drills were taking place within the frequency required. Testing of emergency lighting, fire alarms and fire fighting equipment was also taking place within appropriate timescales. Fire safety records were checked and found to be in order and up to date. All required utility checks and installations were tested and / or serviced within required timescales. Electrical appliance safety checks had also been completed. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 26 Health and safety issues raised earlier in this report are also applicable to these standards in respect of the safe storage and disposal of hazardous substances. All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x 2 x All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 (a) Requirement The registered persons must ensure that all parts of the home to which people who use the service have access are kept free from hazards to their safety. This means that chemicals which may place people who use the service at risk of harm must be stored safely and secured when left. Timescale for action 31/03/08 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 All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 29 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 All Saints Road, 47-49 DS0000061835.V355644.R01.S.doc Version 5.2 Page 30 - 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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