Inspection on 28/12/06 for 71 Coriander Close

This inspection was carried out on 28th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

71 Coriander Close 02/12/08

71 Coriander Close 18/05/05

71 Coriander Close 03/02/05

71 Coriander Close 11/01/05

71 Coriander Close 14/09/04

71 Coriander Close 09/03/04

71 Coriander Close 18/09/03

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 Coriander Close, 71 Northfield Birmingham West Midlands B45 0PB Lead Inspector Brenda O’Neill Unannounced Inspection 28th December 2006 09:55 Coriander Close, 71 DS0000017155.V324229.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 Coriander Close, 71 DS0000017155.V324229.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. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coriander Close, 71 Address Northfield Birmingham West Midlands B45 0PB 0121 460 1846 0121 457 8355 a.wilson@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Ms Amanda Wilson Care Home 3 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) Category(ies) of Learning disability (3), Sensory impairment (3) registration, with number of places Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents Must Be Aged Under 65 Years Date of last inspection 18th May 2005 Brief Description of the Service: 71 Coriander Close is a three bed roomed terraced house, situated in the middle of a housing estate in Northfield, Birmingham. It is registered for three people with learning disabilities and sensory impairment. Trident Housing owns the premises, and Sense in the Midlands are the care providers. The home consists of a downstairs toilet, kitchen with combined area for dining, lounge and sensory room. The laundry facilities are housed within the kitchen area, on the first floor there are three resident bedrooms, a bathroom and toilet and a small staff office. The home is not accessible to people who may use a wheelchair as there is no lift to access the first floor or aids and adaptations to assist people with impaired mobility. To the front of the house there is off road parking. There is a garden to the rear of the house. The fees at the home are based on the individual needs of the residents and at the time of the inspection ranged from £1652.50 to £2449.79 per week. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out over one day in December 2006. During the course of the inspection a tour of the premises was carried out, two resident files were sampled as well as other care and health and safety documentation. The registered manager was not on duty at the time of the inspection so it was not possible to sample staff files. However prior to the inspection the manager had returned a completed pre inspection questionnaire to the CSCI which gave much of the required information about staff. The questionnaire also included other additional information about the home. Additional queries about staffing and complaints were clarified with the manager after the inspection via the telephone. During the course of the inspection the inspector spoke with four staff members. Due to the complex needs of the residents there was no communication with them and they were unable to comment on the quality of care at the home. No complaints had been lodged with the CSCI since the last inspection. One complaint had been lodged with the home. This was about the noise levels in the home at night and was lodged by one of the neighbours. The manager handled this appropriately and a letter was written to the complainant explaining that at times the residents could be quite vocal and apologising for any disturbance. What the service does well: There were good systems in place for determining the goals and aspirations of the residents, who all had very complex needs. Extensive care plans were in place detailing how staff were to assist the residents in meeting their needs and these were regularly reviewed and updated as necessary. Residents likes, dislikes and preferences were clearly detailed in their care plans along with their sensory impairments and how staff were able to communicate with them. To enable the residents to make decisions about their daily lives staff had developed ways of communicating with them, for example, hand over hand and calendar boards with symbols that determined what the planned activities were for the day. There was good guidance in place for staff to follow for any challenging behaviours including what the triggers may be and how to manage the presenting behaviours. Where any physical intervention may be required it was clearly detailed that only appropriately trained staff were to undertake this and what the actions were to be. There was a good range of activities available for the residents to take part in both in the home and out in the community. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 6 There was good documentation of the health care needs of the residents and of how these were met by the staff at the home. The home was adequately staffed by a well trained staff team. Staff turnover at the home was very low. All the staff spoken with had a very good knowledge of the residents and their needs. The interactions between the staff and residents were very positive throughout the inspection. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and the staff were well managed. There was a system in place for monitoring the quality of the service offered to the residents with a view to it being continuously improved. The home provided residents with a comfortable, homely environment in which to live. What has improved since the last inspection? What they could do better: To ensure the safety of the residents there needed to be risk assessments and management plans in place for all the residents’ identified risks. To ensure the medication system was entirely safe the manager needed to ensure that: All medication prescribed for the residents were detailed on the MAR charts. Any balances of medication held in the home at the end of the 28 day cycle were brought forward to the next MAR chart ensuring there was a complete audit trail for all medication held in the home. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The systems in the home ensured that the residents’ individual aspirations and needs were assessed on an ongoing basis to ensure they could be met by the home. EVIDENCE: There had been no new residents admitted to the home for a number of years. The residents living at the home had very complex needs. Their goals and aspirations were determined from the knowledge of the people who have worked with them for some time and influenced by families and friends. Extensive care plans were in place detailing how staff were to assist the residents in meeting their needs. The care plans were regularly reviewed to determine if the needs of the individuals had changed and were updated accordingly. Coriander Close, 71 DS0000017155.V324229.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents had comprehensive care plans and risk assessments that detailed how all their needs were to be met and how the majority of risks were to be minimised by staff. EVIDENCE: Two of the resident’s files were sampled. Both files included extensive care plans and numerous risk assessments. The care plans included comprehensive details about the individuals’ needs in all areas of their lives including: extensive lists of likes and dislikes in relation to how they liked to spend their time, details of their sensory impairments, how staff were to communicate with them and comprehensive detail about their daily routines including personal care needs. The needs of the individuals living at the home were regularly reviewed in monthly core meetings by the staff caring for them. The input to these meetings by the residents was very limited due to their complex needs. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 11 To enable the residents to make decisions about their daily lives staff had developed ways of communicating with them, for example, hand over hand and calendar boards with symbols that determined what the planned activities were for the day. One of the residents had some verbal communication and there were some very specific details for staff to follow about this so that they were able to determine what the individual wanted, for example, phrases they could understand, what the response may be and what this meant. The files sampled included the residents’ wishes in relation to gender sensitive care and what their abilities were in relation to contributing to their own personal care. Residents’ daily diaries gave a good overview of the well being of the residents and how they had responded to their care. Any refusals to partake in activities were detailed showing that staff respected their rights to refuse. The diaries were being signed by the appropriate authors as required at the last inspection. A summary of the risk assessments in place for the residents was kept on each of the working files with a full risk assessment on a separate file. Risk assessments covered areas such as, using the vehicle, going swimming, accessing the kitchen, use of the sensory room and self injurious behaviour. There was good guidance in place for staff to follow for any challenging behaviours including what the triggers may be and how to manage the presenting behaviours. Where any physical intervention may be required it was clearly detailed that only appropriately trained staff were to undertake this and what the actions were to be. It was noted that one of the residents had epilepsy but there was no risk assessment in place for this and it was not clear if the individual had seizures on a regular basis or what staff should do in the event of one. Also one of the residents had a problem where behaviour was causing some damage to their skin. Although staff were very aware of this and how they were to manage it there was only a brief mention in his notes and there was no specific risk assessment in place for this. Coriander Close, 71 DS0000017155.V324229.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were encouraged and enabled to have an independent lifestyle as far as was possible. Their rights and responsibilities were recognised by staff in their everyday lives. The catering arrangements at the home met the needs of the residents. EVIDENCE: All residents had activity plans in place that detailed how they would access the local community and further a field. There was ample evidence in the daily diaries of the residents that they access the local community on an ongoing basis, for example, out for walks, out for a drive in the mini bus, riding school, swimming, trips on public transport and so on. Daily diaries also detailed what the reaction of the individual resident was to the activity and any refusals. Activities were regularly reviewed at the core meetings every month to ensure they were suitable and that the residents enjoyed them. There were photographs around the home of the residents taking part in a variety of Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 13 activities. The staff also informed the inspector that two of the residents had had a holiday in Wales and the other resident’s holiday was booked for February. Activities provided were proving to be the choice of residents. In their personal files there were letters to say that residents do not wish to partake in certain activities. The letters were signed by family members and a representative of the funding bodies. Whilst in the home the activities offered to the residents included foot spas, which they appeared to enjoy very much, listening to music, talking books, use of the sensory room and hair braiding. Contact with the residents’ families was clearly detailed in the residents’ files and staff were able to tell the inspector of how they tried to maintain contact with families where this was proving difficult. One completed comment card was received from a family member prior to the inspection which was positive about the service being offered at the home. The menus at the home were varied and nutritious. The residents’ files included extensive lists of their likes and dislikes in relation to food. One of the residents was causing staff some concern in the way they ate and the risks this posed of them choking. The appropriate professional help had been sought to help them manage this problem but they were seeking further advice as it had meant that the choices available to the individual were becoming quite limited. Details of the food and drinks served to the residents were recorded in their daily dairies. Coriander Close, 71 DS0000017155.V324229.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs were met in ways that suited them. The medication system was generally well managed and ensured residents received their medication at the prescribed times. EVIDENCE: Details of the assistance the residents needed in relation to their personal care was clearly detailed under their daily and night time routines in their care plans. There was evidence that gender sensitive care was being offered wherever possible. Personal care was offered in the privacy of the individuals’ bedrooms and all the residents were well presented. One of the residents had their hair done in a style to meet their cultural needs and there was evidence that the appropriate skin care was also available for the individual. There was a lot of information on the residents’ files in relation to their health care. Details were available for staff of the health risks residents were exposed to because of their sensory impairments and what staff should be observing for and what action should be taken. There was good documentation of the all the Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 15 professional visits the residents had and of what appointments they had attended, for example, visits from speech and language therapists, medication reviews, general GP visits, occupational health visits, dental treatment and optical services. It was also evident that where staff had noticed a change in the behaviour of the residents this was followed up appropriately with the relevant health care professional. Residents were also being weighed on a regular basis. The majority of the medication was being administered via a 28 day monitored dosage system and this was generally well managed. At the time of the inspection there were no controlled drugs being administered in the home. All staff that were administering the medication had been appropriately trained. Some issues did arise about the audit trail for the paracetamol that had been prescribed for the residents. For two of the residents their paracetamol had not been recorded on the MAR (medication administration records) charts and for the other resident it had been recorded but the balance was incorrect as the new box had not been added to the MAR chart. The staff could not explain this at the time of the inspection. The manager was advised after the inspection that all medication prescribed for residents must be recorded on the MAR charts and any balances held in the home at the end of the 28 day cycle must be carried forward to the next month’s MAR chart to ensure there is a complete audit trail. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The complaints and adult protection procedures available ensured that residents were protected from harm. EVIDENCE: There were details on the residents’ files about their abilities to understand how to make complaints. Documentation included how staff would recognise if a resident was unhappy about something. The home had an appropriate complaints procedure that was available in different formats, for example, pictorial and on compact disc. One complaint had been lodged with the home since the last inspection. This was about the noise levels in the home at night and was lodged by one of the neighbours. The manager handled this appropriately and a letter was written to the complainant explaining that at times the residents could be quite vocal and apologising for any disturbance. No complaints had been lodged with the CSCI. Adult protection procedures were not viewed at this inspection but had been seen at previous inspections. Staff had received training in adult protection issues. The pre inspection questionnaire detailed that the staff at the home managed the personal allowances for the residents. Two of the residents had bank accounts for their finances. The other resident had a relative that acted as Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 17 their appointee. The records for the management of the personal allowances were sampled and found to be appropriate. Receipts were available for all expenditure with two staff signatures. The balances checked were correct. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided residents with a comfortable, homely environment in which to live. EVIDENCE: This is a small home much like a domestic dwelling and as such provided residents with a very homely place to live. Furnishings, fittings and décor throughout were of an acceptable standard. Information on the pre inspection questionnaire detailed that the kitchen, lounge, hall, stairs, landing and lounge had been redecorated since the last inspection. The ground floor of the home had a lounge and sensory room, which had had some new equipment installed since the last inspection for residents to experience. One of the residents spent much of their time in this room during the course of the inspection and was very content. There was also a combined kitchen/diner. Laundry facilities were located in the kitchen but due to the layout of the home there was no alternative space for this. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 19 All bedrooms are located on the first floor and of single occupancy. All were appropriately personalised to reflect the personalities of the residents. Two of the bedrooms had been redecorated since the last inspection. The home has one bathroom and toilet located on the first floor with a shower over the bath. This gave the residents the choice of either bath or shower. There was also an additional toilet on the ground floor. The garden to the rear of the home was quite large and well maintained. The patio doors leading to the garden had a retractable awning fitted as one of the residents likes to stand out there in a variety of weathers. There was also a swinging hammock available for the residents to use in the better weather. The staircase and the corridors in the home are quite narrow and therefore the home would not be able to accommodate people with mobility difficulties. The residents living in the home at the time of the inspection were able to find their way around either independently or with guidance from staff. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were maintained by a well trained staff team. EVIDENCE: Staff files could not be accessed on the day of the inspection, as the manager was not on duty. Information received on the pre inspection questionnaire detailed that staff turnover at the home is very low. The majority of the staff team had worked at the home or with the same organisation for a considerable amount of time. The staff on duty at the time of the inspection were very capable and handled the inspection with confidence. All the staff spoken with had a very good knowledge of the residents and their needs. The interactions between the staff and residents were very positive throughout the inspection. There were three staff on duty throughout the waking day at the home as two of the residents had one to one staffing. There was one waking night staff member each night with an on call person for support if needed. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 21 One staff member spoken with commented they received ‘loads of training’. The manager had forwarded the training matrix for the home with the pre inspection questionnaire and this evidenced that staff undertook all their mandatory training and refreshers on a regular basis including fire training, manual handling, food hygiene, infection control and adult protection. Other training topics also covered by staff included, communication, working together with deaf blind people, challenging behaviour, values and none violent intervention. It was noted that one member of staff detailed on the training matrix appeared to be behind with quite a lot of training refreshers. This issue was discussed with the manager after the inspection. She stated this member of staff had come to the home from one of the organisation’s homes and that nominations had now be sent to get all the relevant training updated. There was an extensive induction training pack on site for new employees. Five of the nine staff employed at the home have achieved NVQ level 3. Recruitment records could not be accessed at this inspection however recruitment and selection processes have been found to be robust at past inspections. The pre inspection questionnaire detailed that for the one person employed since the last inspection the CRB check was received prior to them commencing their employment. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensured the smooth running of the home in a competent manner. There was a system in place for monitoring the quality of the service offered with a view to continuous improvement. EVIDENCE: Although the registered manager was not on duty at the time of the inspection it was evident that the home was well managed. Staff were confident in their roles, were able to answer all the questions put to them and knew where to find the required records. The manager has a lot of experience of working with people with sensory impairments and learning disabilities and is appropriately qualified. It was evident from the training matrix for the home that she regularly updated her own training. The outcome of the inspection was Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 23 discussed with her a few days after the inspection. The few issues that had been mentioned to staff she had been told about and was already in the process of addressing. The organisation has a formal quality assurance system in place. The inspector sampled the audit file for this which included audits on health and safety, individual staff audit, finance themed audit and medication audits. There was a self assessment report for 2006 that had been compiled by the manager which results in an operational plan for the home. Previous inspections have also commented on the organisation undertaking a full audit of the service. Due to the complex needs of the residents they do not have meetings. Staff bring the changing needs of the residents to the attention of the manager and all staff at the core monthly meetings. These are then discussed and as a team they decide what action must be taken to meet any needs. Health and safety at the home were well managed. Staff received training in safe working practices. There were extensive risk assessments for the residents and the premises. There was a comprehensive COSHH file on site and COSHH substances were stored securely. All the in house checks on the fire system were up to date and fire drills were undertaken on a regular basis. The recording of fire drills had improved since the last inspection and it was clear when they had been undertaken and who had been involved. There was evidence that the equipment in the home was being regularly serviced. On the day of the inspection the service for the gas cooker and the portable electrical appliances could not be located but these were faxed to the CSCI a short time after the inspection. The systems in place for accident and incident recording and reporting were appropriate. Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Coriander Close, 71 DS0000017155.V324229.R01.S.doc Version 5.2 Page 25 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(4)(c) Requirement There must be risk assessments and management plans in place for all the residents’ identified risks. All medication prescribed for the residents must be detailed on the MAR charts. Any balances of medication held in the home at the end of the 28 day cycle must be brought forward to the next MAR chart. There must be a complete audit trail for all medication held in the home. Timescale for action 01/02/07 2. YA20 13(2) 01/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coriander Close, 71 DS0000017155.V324229.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 Coriander Close, 71 DS0000017155.V324229.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. 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