Inspection on 14/09/07 for 7 Manor Road

This inspection was carried out on 14th September 2007.

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

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

Other inspections for this house

7 Manor Road 09/08/06

7 Manor Road 14/11/05

7 Manor Road 27/06/05

7 Manor Road 08/02/05

7 Manor Road 17/08/04

7 Manor Road 15/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 7 Manor Road 7 Manor Road Stratford On Avon Warwickshire CV37 7EA Lead Inspector Martin Brown Key Unannounced Inspection 14th September 2007 12:00 7 Manor Road DS0000057990.V345897.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 7 Manor Road DS0000057990.V345897.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. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 7 Manor Road Address 7 Manor Road Stratford On Avon Warwickshire CV37 7EA 01789 414552 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.turning-point.co.uk Turning Point Rosalyn Jane Taylor Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2006 Brief Description of the Service: 7 Manor Road is a care home operated by Turning Point. It provides a community based residential care service for five adults with learning disabilities. The home is situated in a residential area close to the town centre and local shops. The home is staffed 24 hours a day. The building consists of two converted semi- detached houses. This results in a degree of separation, with two staircases, one of which has a stair lift, and a central fire door upstairs. There is a large kitchen, laundry and a separate staff office on the ground floor. The majority of residents have profound learning disabilities and communication difficulties, although there is one service user who is more independent and who has good communication skills, but who chooses to remain at the home. Current fees at the home are £1430.20 per week. Transport, hairdressing and toiletries are extra. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been accumulated by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 10th September, between 12am and 4.30 pm. All service users were seen over the course of the inspection, as were staff on both the morning and afternoon shifts. The manager was not present during this inspection. A tour of the premises was made, relevant documentation was looked at, and observations of the interactions between residents, staff and their environment were made. Policies, and procedures and care records were examined, and two service users were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. Specific elements of one other service user’s care were also looked at in detail. The recently introduced Annual Quality Assurance assessment was filled in and returned by the management to further inform the inspection, as was accumulated evidence from regulation 37 notices. Two service users were able to offer views on the care and support they received. One relative was able to be contacted for views. They were very positive, being ‘very pleased’ with the service, and commenting how well the person concerned had done since being at Manor Road. Staff and service users were welcoming and helpful throughout. What the service does well: The home continues to provide a stable and consistent home for adults with a variety of needs associated with learning disabilities. The atmosphere throughout the inspection was one of calm, friendliness and familiarity. Service users gave the impression of being content; one service user who is able to clearly communicate, had time, in a busy day, to say that ‘its good here’. One relative who spoken with was very positive about the service. Experienced staff are familiar with service users’ needs, and service users are obviously comfortable with them. Lots of easy-going interactions were observed, and staff put residents at ease at times of stress. Staff were keen to put right any shortcomings pointed out during the inspection. Photographs provided a good record of activities and outings, and social events. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 7 Manor Road DS0000057990.V345897.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 7 Manor Road DS0000057990.V345897.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. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Prospective residents should feel confident that admission would involve a full assessment of the home’s ability to meet their needs and aspirations. EVIDENCE: There have been no new admissions to the home for over three years. Staff spoken with were unaware of any plans to admit another service user. The Annual Quality Assurance Assessment completed by the manager reaffirmed that new admissions are always made only following full admissions and lengthy introductions. The standards relating to this have previously been met. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 9 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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by care guidelines that reflect and inform staff practice. Accessibility of these may be hindered by unnecessary duplication, and by most information being kept together in large, bulky folders. Service users benefit from a staff team who are aware of their needs, attendant risks, and support them in making day-to-day decisions. The adoption of Person Centred Plans should help ensure that all areas of service users’ lives are looked at, and documented in a way that effectively reflects individual service user’s wishes. EVIDENCE: Care plans are now kept securely, to maintain confidentiality. Two care plans were examined, and included pen pictures, health information, care guidelines, contacts, and risk assessments. Information such as one person’s communication guide, that helps other people understand what she means by 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 10 particular words or phrases, was included in this rather bulky folder, rather than in any separate, more user-friendly ‘communication guide’ or similar. There was some duplication between care plans, care guidelines, and risk assessments, with essentially the same information being provided in two or three different ways in some instances. For example, one care plan gave guidance on how to support a resident on the stairs, which was immediately followed by a risk assessment giving almost the same information, in a less user-friendly fashion. While much information had a date, some otherwise useful information was not dated, thereby limiting its usefulness, and not making it clear when it might need updating. There were some guidelines, undated, on one service user and horse riding. Staff advised that this person had not been horse riding for some time, were unclear as to why not, or when the guidance was written. Monthly evaluations, in the form of photo albums, were seen, showing what individuals had enjoyed and achieved recently. Information in care plans tended to concentrate on guidance to support service users in potentially hazardous daily activities, with their being little other than in brief pen pictures, about aspirations and enabling wider positive experiences and greater steps towards more independence and a better quality of life. Staff advised this was to be addressed with the development of Person Centred Plans. It was apparent from observation, discussion with staff and service users, that service users were supported, to varying degrees, in achieving aims, where these had been ascertained. Some staff commented that they felt there was’ too much paperwork’ and that the organisation introduced too many new initiatives without full guidance on how to implement them, using person Centres Plans, and Active Support plans as examples of this. One care plan looked at gave clear guidance on a person’s likes and dislikes, where the person was unable to clearly articulate these. Service users were assisted in making decisions on varying levels, from going out in the car, to where to sit. While one service user was very clear on making decisions, at least two others needed help in this area, and were given a lot of support, with suggestions as to where they may wish to sit, and what they may wish to do, being given. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to benefit from a variety of activities. Person Centred Plans should help focus activities more directly towards everyone’s identified individual wishes, as long as the service has the resources to meet these. EVIDENCE: One service user was not present for much of the inspection, taking part in regular part-time work for a charity organisation. This person continues to have a very full calendar, with a mix of regular work, educational and social activities, the majority of which are attended independently, with staff support involved mainly in supporting transport to a variety of venues. By contrast, one service user was thoroughly absorbed, when I arrived, with a variety of plastic shapes. Staff advised that she had had an aromatherapy session earlier. Staff were able to detail a variety of activities and venues for individuals, such as clubs, and colleges. Several service users attend church. One chooses not 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 12 to. Photo albums showed service users enjoying a wide variety of activities, with the service continuing to work well to make birthdays and other events special for service users. Staff agreed that the introduction of Person Centred Plans may help identify further activities and interests for individuals, and help them achieve them. Staff also expressed concern that service users’ opportunities for going out where they require one-to-one staffing may be limited by any reduction in staffing The service supports service users in maintaining family relations. One service user had just returned from a prolonged stay with family. Staff advised that a majority of relatives had attended a ‘forum’ at the home the previous day. A neighbour called very briefly to say ‘hello’. An aromatherapist had made a usual weekly visit that morning; staff advised that this was now a regular occurrence, and that all the service users looked forward to this and enjoyed it. Service users either appeared to, or positively stated, that they enjoyed this time. The service continues to provide a variety of healthy food, as evidenced by menus, plans for the evening meal, and food stocks in the home. Staff advised that there were no special diets, other than encouraging healthy eating. Lunch was seen to be an easy-going, leisurely time. Mealtimes have been recognised as a potentially stressful time for a service user with epilepsy, and staff were able to explain the measures put in place, with the support of an outside professional, to reduce any stress and subsequent seizures. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 13 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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from receiving personal and healthcare support from a staff team that is knowledgeable of those needs and able to meet them in a warm and friendly way, with outside professional guidance as needed. Service users may benefit from clearer guidelines in regards to ‘as required’ medication. EVIDENCE: Discussions with individual staff showed that they continue to have a good knowledge of individual health and personal support needs, and how to meet those needs. Regular health appointments continue to take place, as well as specialist appointments. Staff interactions with service users showed that they were aware of and sensitive to particular health care and personal support issues. Health and personal support guidance was in place in individual files. When one service user became temporarily distressed, an agreed strategy for managing this was observed. Staff members spoken to all said that they have had refresher training in epilepsy, and were able to consistently tell how this was managed. Staff were 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 14 able to discuss how, working with a relevant specialist, the service is adopting strategies to help reduce one person’s seizures at meal times. Medication was seen to be accurately and appropriately recorded with good clear guidance on individual residents and their preferences, and good guidance on individual medications and their usage and possible effects. One medication error had been notified in the past twelve months; this had been promptly dealt with at the time. Where a service user has medication with some food, this was now clearly documented and supported by the appropriate health professionals. Some ‘as required’ medication did not give full details of how to judge if it was needed. One pain-killer, for example, noted, ‘give if pain in shoulder’, but it was not clear how this was to be determined. Staff suggested this would be ascertained by movement or posture, or by asking if the service user could make a particular movement comfortably. Staff agreed that clearer guidance on such areas would lead to greater consistency of support to the service user, and also remind them to discuss the desirability of this medication with the service user. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 15 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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the service protects them from abuse, neglect and self-harm. While staff were responsive to service users’ wishes, it was not immediately clear in one recorded incident if a concern expressed by a service user had been followed up. EVIDENCE: Staff were observed being heedful of residents’ views and knowledgeable about day-to-day preferences. Minutes of regular service user meetings were seen, at which such things as holiday plans, parties and other special events were discussed. One of the more recent meetings included a complaint expressed by a service user about the noise at night from the automatic air freshener in the toilet. No response was recorded to this, and staff on duty were unaware of any response. A member of staff contacted at a later Staff advised that a family forum had taken place the previous day, but were unaware of its content, as they had not attended it. Relatives who were able to be contacted were very complimentary about the service. “Very pleased” and “the staff are very good” were among the comments. Residents’ finances were seen to be checked between handovers. These are also checked on a random basis, by a representative of the organisation during ‘Regulation 26’ visits by the Registered Provider. Staff spoken with said they had been on abuse training and demonstrated a good awareness of abuse issues and of what to do if abuse in any form was 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 16 suspected. There were no complaints recorded in the last twelve months in the complaints log, and none had been received by the Commission for Social Care Inspection regarding this service. A relative spoken with had no complaints at all about the service, but felt confident about how to complain in the event of this being necessary. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 17 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): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from continuing improvements to the home, which continues to be clean and hygienic. The size, and siting, of the laundry continues to detract from the overall ‘homeliness’ of the environment. EVIDENCE: The home was clean, tidy, and free from any unpleasant odours on the day of this unannounced inspection. What was previously the sensory room is currently being redecorated. Staff advised that it is intended that this will in future be a second lounge or sitting room, as continued access to get to other parts of the house made it unsuitable as a sensory room. Staff advised that a former bedroom upstairs is to now be used as a sensory room. Well-presented paintings by residents continue to be in evidence on walls in communal areas. The lounge has double doors. These were shut at one point and difficult to open. Staff observed that this may be because there was little clearance between the door and the carpet. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 18 Two bedrooms were seen. These are well-furnished and decorated, and personalised to individual wishes. Upstairs continues to be accessed by two separate stairs, one with a stairlift. The bathroom has a bath chair. Staff advised that, to make the bath accessible to those who do not use the chair, this has to be put in and removed, as required. Full guidance on this was seen. The home continues to have a ‘homely’ feel throughout. The one exception to this continues to be the curious siting of the laundry, which is quite large and occupies a prominent position in the home, being the first thing viewed upon entering the home. Staff and residents may have grown used to this, but it can strike a visitor as imposing, and rather institutional. The contrast between the rather small dining room, and the rather large laundry right next to it, is noted. The garden remains an attractive and, staff advised, a much-used feature of the home. Staff commented that maintenance of it can be problematic. There is a lot of greenery, and tables and chairs for sitting outside in good weather. A staff member said that one resident, who had yesterday become distressed at activities within the home, had instead enjoyed picking flowers in the garden with her instead. The flowers were displayed on a table. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 19 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the attentions of a consistent staff team who are familiar with their needs and how to meet them. Service users safety is potentially compromised if professionals from outside the service with unsupervised access to service users do not have up-to-date Criminal Records Bureau checks. EVIDENCE: There were two staff on duty in the morning, and two on duty in the afternoon. Staff advised that there were normally three staff on duty, but there had had two on duty lately, whilst one service user, who had just returned, had been away. Having two staff on did not pose health and safety problems within the home, but limited what activities could take place if all service users were at home. One service user was transported to afternoon employment that day. One other service user was able to take this opportunity to go for a ride in the car. I was advised by staff that, on other days, when service users take part in other day services and activities, those remaining in the home have more opportunities for activities. Staff expressed concern that any reduction in staffing would impact on the ability to support activities outside the home. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 20 Unexpected sickness in the afternoon shift posed difficulties for the service in ensuring the shift was fully covered. Current rotas showed that the service uses minimal agency support, being mostly able to rely on existing staff to staff the service. Staff on duty were all familiar with the needs of the service users and how to meet them, and friendly and relaxed, but professional, interactions and support by staff were observed, throughout. Service users were relaxed and comfortable with staff. A relative commented that ‘the staff are very good.’ In the absence of the manager, staff and recruitment files were not able to be examined. These were seen as satisfactory during the previous inspection, and information concerning these provided on the Annual Quality Assurance Assessment returned by the service gave no reason to think anything other than proper staff recruitment procedures for protecting service users are not still fully in place. The aromatherapist who regularly visits and has unsupervised access to service users said that, while he had had police checks some years ago, he was not aware of having had a Criminal Records Bureau check. Upon discussion, he was quite happy to undertake this if required to. Staff were able to confidently discuss training and its application, and were positive about the training opportunities. The Annual Quality Assurance Assessment returned by the service detailed its commitment to training and confirmed a satisfactory percentage of staff having achieved National Vocational Qualification level 2. One staff spoke of wishing to do level 3 and hoping for financial support to achieve this. Staff were seen to be capable and responsible in the absence of the manager, and able to access on call support as needed. One staff member felt it would be preferable to have specified ‘seniors’ rather than the current system of one person being ‘in charge’ on the basis of them ‘sleeping in.’ 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 21 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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to benefit from a service that is well-run, takes account of their views and promotes the health, safety and well-being of service users. EVIDENCE: The manager was not present during this unannounced inspection, but staff showed themselves capable and competent in her absence, and aware of how to get on-call advice and support if needed. Staff were keen to rectify any shortcomings noted during the inspection as quickly as possible. Copies of records regular service users’ meetings were seen, which showed a commitment to involving service users in decisions in the home, although, as previously noted, these need also to detail any response to issues raised by service users. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 22 Regular visits by the registered provider’s representative, which highlight good practice, as well as areas for improvement, continue to take place. Staff advised that a family forum, with the service manager in attendance, had taken place the day before. The Annual Quality Assurance Assessment filled in by the management lists appropriate health and safety checks as taking place. Records of fridge/freezer and hot water checks were filled in appropriately. No hazards were noted during this inspection. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 24 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 YA34 Regulation 19 Requirement The home must ensure that workers having unsupervised access to service users have had appropriate safety checks, to ensure that service users are fully protected. Timescale for action 19/10/07 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. Refer to Standard YA6 Good Practice Recommendations It is recommended that all service user communication information is updated, and that communication guides are maintained, separate from the main care files, as accessible ‘user friendly’ guides for all, so that these are readily available for easy reference by staff and service users. Information concerning residents should be dated and signed, to ensure it is up-to-date, and to facilitate timely reviews of this information. ‘As required’ medication should be have clear details as to when and why it is required, and involve the service user in this decision as fully as possible, so that they are as DS0000057990.V345897.R01.S.doc Version 5.2 Page 25 2. 3. YA6 YA20 7 Manor Road 4. 5. 6. YA22 YA24 YA24 aware as can be of the medication they are taking. The service should be able to evidence that items raised at service users meetings have been responded to, to show that service users’ views are heeded and acted upon. If ever major work is to take place in the future, consideration should be given to the siting and size of the laundry, to help the home appear more ‘homely’. Ensuring the lounge doors were easier to open would lessen the potential for difficulties for residents in entering and leaving the lounge. 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 7 Manor Road DS0000057990.V345897.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!