Inspection on 30/06/08 for 7 School Drive

This inspection was carried out on 30th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

7 School Drive 27/09/06

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 28/09/2008.

CARE HOME ADULTS 18-65 School Drive, 7 7 School Drive Bromsgrove Worcestershire B60 1AX Lead Inspector Dianne Thompson Unannounced Inspection 30th June 2008 09:30 School Drive, 7 DS0000066847.V366611.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 School Drive, 7 DS0000066847.V366611.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. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service School Drive, 7 Address 7 School Drive Bromsgrove Worcestershire B60 1AX 01527 874827 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.dimensions-uk.org Dimensions (UK) Ltd Julie Dawn Duggan Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2006 Brief Description of the Service: School Drive is a purpose built bungalow located in Bromsgrove about a quarter of a mile from the town centre. The service provides personal care in an ordinary environment, for up to five adults with learning and physical disabilities. School Drive has a large lounge/dining area, five bedrooms, a bathroom with toilet, one separate toilet, a shower room, laundry, office area and fully fitted kitchen. The service is committed to helping people achieve valued and fulfilling lifestyles. The manager is Julie Duggan. Dimensions (UK) Ltd is the care provider for the service. Details of current fees for the service are included in the service user guide. School Drive, 7 DS0000066847.V366611.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 this service is 3 stars. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection visit to see what the service was like for people who live at School Drive. Time was spent talking to some of the people who live at School Drive and some of the staff working there. We looked at some of the policies and procedures in the office with the senior staff on duty. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at School Drive and the ways they plan to make the service better. A tour of the home was also made. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI has been included in this report. What the service does well: School Drive gives clear information to people about their service to help people and their families to make decisions about their future care needs. Before anyone is offered a service, the manager will check that School Drive can give the support that is needed. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. School Drive provides opportunities and support for people to maintain their interests and any hobbies they may have. School Drive looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to keep people well and healthy. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. School Drive makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at School Drive. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 6 Staff help people to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and varied menu. Staff are trained to give support to people who need help with eating and drinking. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. 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. School Drive, 7 DS0000066847.V366611.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 School Drive, 7 DS0000066847.V366611.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 excellent This judgement has been made using available evidence including a visit to this service. Information is provided for people and their families to help them decide if the service can meet their needs. School Drive completes detailed assessments for people before a place is considered to make sure that all their needs can be met. EVIDENCE: School Drive has policies and procedures in place for assessing potential people to live at the home. Information about the service included in a Statement of Purpose and Service User guide is available for all enquirers and residents. Information is available in signs and symbols to make it more accessible. There are currently no vacancies at School Drive. The admissions procedure states that people would be given an information pack containing a copy of the statement of purpose and service users guide on admission. The statement of purpose and the service users guide now provides information in a simplified format so that people can understand it. The admissions procedure states that full community care assessments would be required and School Drive would complete their own assessments. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 9 Files for three people were examined. Each file contained a community care assessment and the service assessment. School Drive’s assessment determines the level and kind of support that is needed and includes views from other interested parties where this is appropriate. The assessment process is very detailed and thorough, and demonstrates a person centred approach. Assessment topics include ‘how I communicate, my interest, religion, my education, my routines, my health and personal care needs and helping me stay safe’. Information is used to develop a care plan that includes a health assessment and relevant risk assessments. Surveys confirmed that information about School Drive is shared, and that people are kept up to date with important issues. School Drive, 7 DS0000066847.V366611.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, 9 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are identified in care plans. These plans provide information to make sure that care and support is provided in a way that people want, and in a way that respects privacy and dignity. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Staff support people to take risks in ways that helps them keep their independence as much as possible. EVIDENCE: Care plans have been updated and transferred into Dimensions formats. This new format was being introduced at the time of the last inspection. Alternative communication methods are now used so that people who use the service can School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 11 access information more easily. The abilities of people are diverse and individual formats are required, such as widget symbols, audiotapes or the written word. For those people with little or no understanding of the care plan process, statements are included in their care plans that explain this. Care plans for three people were viewed and all contained appropriate information about their needs and how they were to be met. Information provided in these care plans cover all aspects of each person including their daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. Information is provided about how people communicate. The manager states in the AQAA that ‘the people we support are not able to express their views verbally. We observe peoples responses to the support they receive, this can tell us if the service we provide for each person is suitable to meet their needs. We also value views of family, friends and carers of the people we support’. Care plans set out in detail the action that needs to be taken by staff to make sure that all support is given in a consistent way. Staff are fully aware of care plans and use them to guide their practice. Each person is allocated a key worker to oversee his or her care. This allows staff to work on a one-to-one basis and contribute to planning care support for each person. We saw tht each person keeps their records in their own room. Individual risk assessments are used to help and support people maintain their independence, and cover all areas such as health, mobility, moving and handling, and the management of the risk of choking. We saw risk assessments that have been reviewed and updated, such as wheelchair use, hoist and choking interventions. Surveys confirm the care and support provided at School Drive is what is expected or agreed with the service, and that people who use the service are treated respectfully at all times. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 12 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 excellent This judgement has been made using available evidence including a visit to this service. Staff help and support people to have opportunities to take part in their choice of activities that make the most of their abilities. People are encouraged to follow personal interests and activities in their chosen lifestyle. People are supported to keep in touch with their families and friends. Although people have different dietary needs, these are well catered for with food that is varied and healthy. EVIDENCE: People are given support and encouragement in making choices about how they spend their time. We saw people making choices about how to spend their day during the inspection visit. One person returned from a day out with a supporter. The trip included lunch and time in the park and both people seemed to have thoroughly enjoyed their day. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 13 Daily activity sheets monitor what each person has chosen to do throughout the day both at home and in the community. Activities on offer include shopping, swimming at the hydrotherapy pool, eating out, visits to the cinema, and going on holidays. Occasional trips such as visits to the coast are arranged and seasonal celebrations are also organised. School Drive now has a pleasant seating area in the garden and people will be encouraged to spend time there, particularly in the summer. Staff are flexible with hours of support so that people are able to visit the cinema, pubs for meals, concerts or other venues during evenings and the weekend. A monthly audit of activities is carried out to be to see if people have had the opportunity to do the things they enjoy and to see whether they have had the opportunity to try new activities. A selection of places to visit is listed on the staff notice board as a prompt and also for people to add suggestions. We saw from records that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirmed that they are made welcome and offered a drink. Varied and nutritional meals are provided and alternative meals are available where these have been chosen. Some people have specialised dietary requirements for specific health conditions. We saw that a record of meals is kept on individual menus and food charts. These menus and food charts are kept in the kitchen to allow for easy access by staff preparing meals and drinks. Alternative options, special diets and preferred choices are recorded. Records of all food and drinks taken are transferred into individual care plans. This includes food supplements. Support is given for people who find it difficult to eat and need help. Staff confirmed that they do this in a sensitive way that lets people to eat at their own pace. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 14 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. Personal and healthcare needs are identified in care plans. These plans provide information to make sure that care and support is provided in a way that people want, and in a way that respects privacy and dignity. The service has guidelines for staff to follow to make sure that everyone is supported to take their medicine safely. EVIDENCE: Care plans give details about each person’s daily living needs, health and personal care, social interests and relationships. Risk assessments are completed as part of the care plan process. We saw records that show regular checks and monitoring are being carried out. Each person has a Health Action Plan folder which they keep in their rooms. People have good access to medical support through their Primary Health Care team as required. This includes occupational therapists, dentists, GP, dietician, community nurses, consultant psychiatrists, and a speech and language School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 15 therapist. A record of all visits to the doctors or other medical professionals is kept. School Drive has a medication policy and procedure in place. Health assessments include information on the management of specific health issues or concerns, and emergency procedures. Where people are prescribed medication, details and arrangements for taking medication is included in their care plans. Details about possible side effects of medication are also made available. The manager and assistant manager are completing training that will allow them to deliver medication training to the staff team. Medication information sheets in health action plans were checked and found they did not match the information on the medication administration records. We saw examples where medication such as sodium valproate had been discontinued for one person but this had not been updated on all records. This was discussed with the senior on duty and it was agreed that although the medication administration records were correct all records should contain up to date information. All files are to be checked and all information is to be updated. Medication is stored securely and given to people at the right time and full records are kept which show this. Medication administration was observed and tablets were given appropriately. Medication records are completed as required. Recommendations from the previous inspection have been completed. These included updating emergency hospitalisation profiles, and dating medication information fact sheets. We saw an example of responding to a person’s changed needs where a risk had been identified for one person and staff discussed their concerns with the speech and language therapist. As a result medication for one person has been changed to liquid form to help keep the individual safe. Staff were observed providing support for people in a respectful way, making sure that dignity and self esteem was important for each person. Although communication with people who use the service for visitors may be difficult, people appeared to be comfortable and at ease in their surroundings. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 16 School Drive, 7 DS0000066847.V366611.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): 22, 23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. School Drive has a complaints policy and procedure that they follow should any complaints be made. Staff support people to express their views and any concerns they may have. A record of all complaints is kept and the action taken to respond to them. Guidelines and staff training are in place to make sure that people who use the service are protected from abuse, neglect and self-harm. EVIDENCE: School Drive has a complaints policy and procedure in place which is accessible to people who live at School Drive and their relatives. Staff support people should they wish to make a complaint. Surveys confirm that people are aware of the complaints procedure and that people have not made any complaints. The manager confirms in the AQAA that no complaints have been made to the service. The CSCI has not received any complaints about School Drive. As people who use the service are totally dependent upon staff for their care, staff confirmed they would advocate for people should there be any concerns. The manager stated in the AQAA that ‘vulnerability risk assessments have been completed to identify areas where people are vulnerable and the need for a risk assessment to support and protect the person’. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults. Staff are given training in abuse School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 18 awareness and adult protection and staff training records confirmed this. Staff said that they are familiar with the procedures to be followed. People who use the service are supported to manage their money. The senior staff member said that money and accounts for people living at School Drive are audited each month as part of their regular monitoring process. People are supported to keep their monies and valuables in their rooms, in a suitable locked safe. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who live at School Drive enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted. School Drive is a purpose built bungalow, with a large lounge/dining room, five bedrooms, one bathroom with toilet, one shower room, a separate toilet, laundry, office and fully fitted kitchen. There is an enclosed rear garden and small front garden. The lounge and dining area is comfortable and well furnished. There is a ramp from the patio door that provides easier access to the garden. School Drive has its own vehicle for people to use locally. The property is accessible, comfortable and is homely for the people who live there. The manager states in the AQAA that ‘each person has been supported by their keyworker to have an individually decorated bedroom, each person has School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 20 personal posessions that reflect their interests and that are appropriate to their age, and taste, they also have equipment that has been assessed to meet their needs’. We saw examples of specialist equipment that is being used such as ceiling tracking hoists and slings, and sensory equipment. There have been improvements to the home since the previous inspection. A gated access has been created to the side of the building, and a garden seating area has been made. A gazebo provides appropriate shade so people can sit in the garden safely. The hallway has been painted which was a requirement of the previous inspection. All of the carpets have been professionally cleaned. There are plans for two bedrooms to be decorated, and new kitchen and utility units and tiling to be fitted. The home is clean and tidy throughout. The service has a daily cleaning rota to maintain cleanliness, hygiene and infection control. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are kept in locked cupboards in the laundry room. Staff were seen wearing suitable protective clothing for the work they were doing, and we saw that they are familiar with the procedures regarding the control of infection. Records show that staff have been given training in health and safety matters. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Dimensions make sure that suitable staff are employed and that all necessary checks are made to keep everyone safe. Suitable staffing levels are maintained and staff are given relevant training to provide appropriate care to the people they support. The manager supports the staff team to provide people who use the service with consistent and quality care. EVIDENCE: School Drive has a committed staff team. Staff spoken to confirmed that the team are very well motivated and work hard to improve the lives of the people who use the service. People commented in surveys that they were generally satisfied with the service and the staff. Dimensions has a recruitment and selection procedure that follows the Code of Practice relevant to the provision of residential care. The manager has recently recruited new staff that should mean the service will become fully School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 22 staffed. Staff records were examined for two members of staff and all contained the required information such as proof of identity and a photograph. Staff records are very well organised. Information is held in individual wallets with records available for inspection, supervision and sickness absence. The manager confirmed that all prospective staff complete a written application form, and at least two references are obtained including one from their previous employer. Appropriate criminal records (CRB’s) and other checks are undertaken before appointments are confirmed. Staff confirmed that recruitment procedures are followed. The service is committed to a staff training programme and opportunities. Staff complete a comprehensive training programme throughout their employment, which includes NVQ in Care. Four members of the staff team are currently working towards their NVQ level 2 and 3. Three staff recently completed NVQ level 3 and means that five permanent members of staff team of twelve are now NVQ qualified. Staff receive mandatory training including health and safety, manual handling, fire safety and first aid. Additional training courses include communication, safe handling of medicines, abuse and working with people we support. Staff appeared to be enthusiastic and well motivated. They stated they are well supported and are given the opportunity to share their views and opinions at staff meetings. Regular team meetings take place and minutes are kept. Staff now have specific areas of responsibilty within the service such as fire safety, organising staff training, and health and safety. The manager says in the AQAA that ‘a shift leader is identified on the rota for each shift’. ‘Good communication systems’ are in place so that staff can share information and conduct a handover for each shift. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People who use the service receive a consistent and well-managed service. Staff receive the leadership and support they need. Dimensions monitors the home in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Julie Duggan has many years experience working with people with learning disabilities. Julie is a qualified learning disability nurse, has completed her Registered Managers’ Award (RMA) and is an NVQ Assessor. Julie regularly completes training relevant to her position as registered manager of School Drive, including first aid and prevention of abuse training. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 24 Management responsibilities in the home are also shared with two senior support workers. They are all involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. Julie was not at School Drive at the time of the inspection visit, but the inspection process was well supported by the staff on duty. Staff confirmed that the manager is approachable and supportive. The manager says that all documentation with directions for staff to read ‘have dating and signing sheets attached to them to ensure that everyone working within the home has read and understood information and instructions’. We saw that the management of the service works to planning through the Person Centred Path Map that is regularly updated. These Maps identify aims for the service that are linked to individual plans for people who use the service. The manager completed the Annual Quality Assurance Assessment (AQAA) and sent this to the CSCI when we asked for it. The AQAA is informative and provides evidence to show how support is delivered and talks about the plans to develop the service. Dimensions monitor the service and how it is being run. This includes interviews with staff and people who use the service. A regular audit takes place and includes records, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of School Drive’s quality assurance and monitoring system that is intended to form an annual development plan for the service. The report includes the views of people who use the service, stakeholders and interested parties about the service that is provided. Supervision of care staff includes all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and staff confirmed that regular supervision takes place. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. We saw that fire records are up to date and this includes staff training and fire drills. Staff are trained in mandatory health and safety training topics. Risk assessments are carried out and recorded for safe working practices such as the use of slings on hoists. The records relating to accidents within the service are completed in full and are accurately maintained. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 25 Surveys confirm the service is well managed and that the manager and staff are approachable. The manager states in the AQAA that ‘we have received good feedback from student nurses on placement from Worcester University’. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 26 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 4 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 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 3 X X 4 X School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA19 Good Practice Recommendations All medication information fact sheets should be updated to reflect the information on the medication administration records. School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 28 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 School Drive, 7 DS0000066847.V366611.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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