Inspection on 10/01/07 for 75 Ludford Road

This inspection was carried out on 10th January 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

75 Ludford Road 25/11/08

75 Ludford Road 07/03/06

75 Ludford Road 20/06/05

75 Ludford Road 07/12/04

75 Ludford Road 22/06/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Ludford Road, 75 Bartley Green Birmingham West Midlands B32 3PQ Lead Inspector Brenda O’Neill Key Unannounced Inspection 10th January 2007 09:30 Ludford Road, 75 DS0000016868.V326179.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 Ludford Road, 75 DS0000016868.V326179.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. Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ludford Road, 75 Address Bartley Green Birmingham West Midlands B32 3PQ 0121 683 8855 0121 683 8855 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) Mind in Birmingham Shelagh Munro Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65. That the home can provide a service to 8 residents for the purpose of a Mental Disorder. 8 MD That a Registered Manager is in post by the 1st February 2006. Date of last inspection 7th March 2006 Brief Description of the Service: 75 Ludford Road is a home that provides care and support for 8 people with mental health issues who are aged between 18 and 65 years. The unit is managed by MIND and the accommodation owned by Focus Housing who take responsibility for the maintenance and upkeep of the building. The accommodation provided consists of eight single bedrooms. The home in the main is decorated to a high standard. The communal space consists of one large lounge, which is the designated smoking area, there is a lounge / dining area which is non-smoking and there is also a large kitchen. The rear garden is very pleasant, having a sheltered seating area, lawn and bedding plants. Within a close distance to the home there are a range of community facilities including, shops, pubs, churches, leisure facilities and a medical centre. The immediate area has a good public transport system. The fees at the home are £750.00 per week. Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key inspection over one day in January 2007. An ‘expert by experience’ also visited the home as part of the inspection. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. During the course of the inspection a tour of the premises was carried out, one staff and two residents’ files were sampled as well as other care and health and safety documentation. The inspector spoke with the manager, service manager, four staff members and three of the seven residents. The ‘expert by experience’ met all the residents that were at home at the time and spent the majority of her time at the home talking to them. Prior to the inspection the manager of the home had returned a completed a pre inspection questionnaire to the CSCI which gave some additional information about the home. There had been no complaints lodged with CSCI since the last inspection. The home had logged one minor complaint which was a dispute between two residents. This had been managed appropriately and the issue had been resolved. What the service does well: Prospective residents were fully involved in the pre admission process and could visit the home and stay overnight if they wished before making a decision about moving in. Residents were fully involved in drawing up their care plans. They made decisions about their lives on an ongoing basis and were supported to take risks. Where this may indicate a risk to their physical and or mental health strategies were in place to help reduce the level of risk. Residents were supported to have an independent lifestyle as far as possible, which the home encouraged and supported them to achieve. Their rights and responsibilities were recognised in their every day lives. The expert by experience spoke with all the residents who were in the home and they all said how happy they were with the support they were getting. Residents were encouraged to keep in touch with their families where this was appropriate. If residents did not want to see family members staff knew this. Residents spoke about their friends and having them visit them at the home. Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 6 The residents appeared happy with the catering arrangements at the home. The menus were varied and nutritious and healthy eating was encouraged as much as possible. Complaints made by the residents were listened to and acted on appropriately. There was little staff turnover at the home which was very good for the continuity of care of the residents. Relationships between the staff and the residents were very good. Staff were knowledgeable about the needs of the residents. The expert by experience commented ‘there seemed to be good interactions between staff and residents.’ One resident commented to the expert by experience ‘there isn’t a thing I would change.’ The recruitment procedures in place for new staff were robust and ensured the residents were protected. The home was comfortable, safe and well maintained. The home had a very experienced manager and there was no doubt the home was run in the best interests of the residents. The health and safety of the staff and residents at the home were well managed. What has improved since the last inspection? What they could do better: To further improve the safety of the residents there needed to be risk assessments and management plans in place for any identified risks that residents may be exposed to. To ensure the medication system was entirely safe there needed to be written guidelines in place for staff to follow so that they could determine when as and when necessary medication was to be given to the residents. Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 7 There needed to be clear evidence on site that all staff had received all the required training with the necessary updates to ensure they were equipped with all the necessary skills and knowledge to support the residents. 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. Ludford Road, 75 DS0000016868.V326179.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 Ludford Road, 75 DS0000016868.V326179.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 and4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents were fully involved in the pre admission assessment process that ensured their needs could be met by the home. EVIDENCE: The files for two residents were sampled. Both had been admitted to the home since the last inspection. They included evidence that an extensive assessment had been carried out prior to admission. The assessments included information gained from other agencies, the staff at the home and the individual themselves. The referral forms had been partially completed by the people to be admitted to the home and included information about their aims and goals in life. The files also evidenced that there had been extensive introductory visits to the home prior to admission where possible. Overnight stays were included wherever possible. This gave the individual the opportunity to assess what the home could offer and some time to get to know the other residents. During these visits staff were able to further assess the needs of the individual and ensure the home were able to meet them. Ludford Road, 75 DS0000016868.V326179.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 were fully involved in drawing up their care plans. They made decisions about their lives on an ongoing basis and were supported to take risks. Where this may indicate a risk to their physical and or mental health strategies were in place to help reduce the level of risk. EVIDENCE: Both files sampled included life style plans. The life style plans had been written from the individuals’ perspective but also included issues that staff needed to know to enable them to support the person appropriately. Areas of need identified included a healthy balanced diet, maintaining personal hygiene, helping to budget, and areas of vulnerability. The life style plans identified individuals’ preferences, what was essential to them and what was important to them with guidance for staff as to how they were to successfully support the individual. One of the files was still in the process of being completed, as the individual was quite new to the home and as further information was gathered this was being included in the life style plan. For example, two of the residents Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 11 had developed a close relationship and issues around this was evidenced as being discussed with them in daily records and was in the process of being added to the respective life style plans and risk assessments. Monthly evaluations were undertaken by staff with the involvement of the residents, where they agreed to this. The evaluations detailed such things as activities and health care visits as well as an overview of the general well being of the residents. There were numerous risk assessments in place on the files sampled. These included evidence that the residents had been involved in drawing them up and that they agreed with them. Areas detailed included such things as smoking, exploitation, aggression, neglect and returning late to the home. All the risk assessments included the triggers, early warning signs and the action to be taken. The files sampled included management plans for any relapse in the individuals’ mental health. One of the residents spoke to the inspector about the restrictions that were in place for ‘their own good’ and that they had agreed to these. Two issues were raised with the manager that were not detailed in the appropriate files. One was that a resident could have seizures but there was no risk assessment in place for this or what staff should do should this occur. The other was about a resident who did not want to see a relative who occasionally visited or telephoned the home and this could be problematic for staff. Staff knew what to do when this occurred however it needed to be documented so that any new staff would have some written guidance to follow. Residents in the home made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. They were fully involved in drawing up their life style plans and deciding what they wanted to do and how staff would need to support them. They were fully involved and aware of the risk assessments in place for them for their protection. Residents were able to come and go from the home as they wished within the limits of any risk assessments in place. Throughout the course of the inspection it was evident that the residents chose how they spent their time. Staff encouraged the residents to take an active part in the day to day tasks around the home but if they declined this was respected. Ludford Road, 75 DS0000016868.V326179.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 supported to have an independent lifestyle as far as possible, which the home encouraged and supported them to achieve. Their rights and responsibilities were recognised in their every day lives. Residents were satisfied with the meals at the home. EVIDENCE: Residents accessed a lot of the local community facilities including pubs, restaurants, health care facilities and shops. They regularly went out with staff as well as on their own. One of the residents had access to a deaf club which they attended when they wished. Residents were encouraged to attend structured day placements but many refused and determined their own lifestyles. One of the residents was involved with an occupational therapy service to help them do more things for themselves. All the residents were able to use public transport independently but one resident was escorted by staff due to the risk assessments in place for them. Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 13 Residents appeared very settled at the home and one of the new residents stated they had just had ‘the best Christmas they had ever had’. Relationships between staff and residents were very good. The expert by experience commented ‘there seemed to be good interactions between staff and residents.’ There were occasions when staff had to be quite firm with residents but residents understood the reasons for this. Staff spoke to the inspector about how important it was to recognise and be able to balance the rights of the residents and their responsibilities in their every day lives. Staff were continually encouraging residents to take some responsibility in the home for tidying up after themselves and undertaking such things as cooking, washing up and doing their own laundry. All residents had keys for their own bedrooms and to the front door. There were written details on the files sampled about staff entering their bedrooms and this had been agreed with the individuals. All the residents managed their own money to whatever degree had been agreed with them. Some were totally independent and others were supported by staff to budget on a weekly or daily basis. Residents were encouraged to keep in touch with their families where this was appropriate. If residents did not want to see family members staff knew this. Residents spoke about their friends and having them visit them at the home. Daily records evidenced that residents often went and stayed with their families. Two of the residents in the home had developed a very close relationship and this had been respected by staff allowing them privacy at all times. The manager had spoken to the residents involved about the issues that may arise to try and ensure that both were safe. This home clearly revolved around the residents and there were no set rules or routines that were not documented in risk assessments. The residents appeared happy with the catering arrangements at the home. All residents prepared their own breakfasts. Lunch and tea were prepared and cooked with the help of the residents where they agreed to do this. The home had been without a cook trainer for some time but were trying to appoint to this position. Staff at the home were undertaking the cooking. The home had a four week rotating menu which was on display for the residents. Residents were aware that if they did not want what was on the menu for their main evening meal they must let staff know by 1pm. The menus were varied and nutritious and healthy eating was encouraged as much as possible. Ludford Road, 75 DS0000016868.V326179.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 received individual support to maintain their personal care needs and were able to access and receive support from community healthcare services as needed. The practices and policies of the home ensured that medicines for residents were managed safely and in accordance with the prescription. EVIDENCE: The assistance with personal care needed by the residents was minimal it was mainly prompting by staff to ensure their personal hygiene was to an acceptable standard. Any encouragement and prompting needed was clearly detailed in the individual lifestyle plans. There was very good documented evidence that both the physical and mental health care needs of the residents were being met. It was evident that staff were quick to identify any health care issues and address them appropriately. For example, a resident recently admitted to the home had a dental problem and had quickly been referred to the dental hospital and had attended an appointment and because of the long waiting list for treatment a local dentist Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 15 was being consulted for advice. Another resident who should have had hearing aids but did not on admission to the home had attended hospital for new hearing aids. This person also had access to the deaf mental health services. All the residents were registered with the local G.P. and attended the local surgery as necessary. The manager stated that since this service had moved to Ludford Road the residents had received much more support from the local mental health team and outreach team. Residents saw their social workers and any other specialist workers on a regular basis, for example, drug workers. All the residents had risk assessments in place that detailed how staff would recognise if their mental health was relapsing and who they were to contact. Any relapses were generally managed by the home with support from the appropriate health care workers but if necessary hospital admission was arranged. One of the residents was in hospital at the time of the inspection and staff were keeping in regular contact by visiting and over the telephone. One of the residents at the home administered all their own medication. Risk assessments were in place for this and compliance checks were undertaken. The home administered the medication for all the other residents. The majority of this was administered via a monitored dosage system. The system was well managed. On the day of the inspection it was evident how carefully staff checked the medication received into the home as an error had been found and staff took a lot of time on the phone trying to sort the error out. There was some boxed medication in the home and these were audited. All the balances checked were correct and there was a full audit trail. It was noted that some of the medication was to be administered PRN (as and when necessary) but there were no specific written guidelines for staff to follow as to when this should be administered. The manager was to address this immediately. Controlled medication was being administered appropriately. Staff at the home did not administer medication until they had received the appropriate training. Ludford Road, 75 DS0000016868.V326179.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. Complaints made by residents are listened to and acted on. Residents’ needs in respect of being protected from abuse are met including safe management of their money. EVIDENCE: There was a complaints procedure on display in the home which gave details of the CSCI if they wished to contact them. There had been no complaints lodged with the CSCI about the home since the last inspection. One minor complaint had been logged by the manager at the home which was a dispute between two residents. This had been managed appropriately and the issue had been resolved. The policies and procedures for adult protection were not viewed at this inspection. They had met the required standard at the previous inspection and no changes had been made. All staff at the home had received training in adult protection issues. Some of the residents managed their own finances others were supported by the home. The records kept in the home were sampled. The records were accurate with all transactions being clearly documented and signed for by residents and countersigned by staff. The balances checked were correct. Ludford Road, 75 DS0000016868.V326179.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, 25, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, safe and homely environment that meets their individual and collective needs. EVIDENCE: Both the inspector and the expert toured the home by experience. The inspector only viewed one vacant bedroom but the expert by experience viewed two occupied rooms with the permission of the occupants. Comments about the environment from the expert by experience included: ‘The lounge was homely with pictures and ornaments and smoking was permitted in this room. There was a dining room next door where people did not smoke. So there was a choice of where people sat to eat their meal. Two service users showed me their rooms which varied in size but which both had a wash hand basin.’ Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 18 The home was found to be safe and well maintained. Residents spoken with were satisfied with the environment. Furnishings and fittings were domestic in design and of an acceptable standard throughout the home. The communal areas comprised of a large lounge and a dining room. The lounge was the smoking area for the home. There was a large well equipped kitchen and a new built in oven had been installed. Also on site waiting to be fitted was a new hob and work surface. The residents had access to the kitchen at all times. There was ample outdoor space for the residents in the rear garden which was well maintained and had seating for the residents to use in the better weather. Bedrooms were all of single occupancy. The vacant room on the first floor was in the process of being refurbished. One of the resident had a hearing impairment and had two bell pushes outside their door. One that activated a vibrating pillow to alert them to callers or the fire alarm. The other activated flashing lights in the bedroom or the bathroom which would also alert the resident. The home had one bathroom and a shower room on the first floor and a shower room on the ground floor. These appeared to meet the needs of the residents at the time. There was an ongoing programme of redecoration in the home. Since the last inspection the hall, landing, stairs and one bedroom had been redecorated and the ground floor shower room was in the process of being redecorated. The home had a separate laundry room for the residents and staff to use which was equipped with washing machine and tumble drier. The home was clean and hygienic at the time of the visit. Ludford Road, 75 DS0000016868.V326179.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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with support from a team of staff who are knowledgeable, well supported and who have an awareness of the changing needs of residents. Recruitment procedures were robust and protected the residents. EVIDENCE: It was evident throughout the course of the inspection that staff on duty knew the needs of the residents and how they were to support them. Relationships between the staff and residents were very good and residents were very positive in their comments about the staff team. There is little staff turnover at the home which is very good for the continuity of care of the residents. There are a minimum of two support workers on duty throughout the waking day with one staff member sleeping in each night. The manager’s hours are supernumery to the support workers rota. The home also employs a domestic assistant five days a week. At the time of the inspection there was a vacancy for a cook trainer and one support worker. Staff were Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 20 covering the cooking duties and a regular member of the bank staff was covering the vacant support worker hours until these posts could be filled. The recruitment records for the one new employee were sampled. All the appropriate records and checks were in place including a completed application form, two written references and a current CRB check. It was evident when sampling staff files that they undertake a lot of training both in safe working practices and areas directly related to mental health. Certificates seen included, food hygiene, fire safety, self-harm, working with voices, protection from abuse and emergency aid. It was not possible to establish if all the required training in safe working practices was up to date as the home did not have training matrix identifying this in place. For example it could not be established when some staff had undertaken health and safety and manual handling training. This was discussed with the manager who was address. The pre inspection questionnaire stated that eighty percent of the staff had achieved NVQ level 2 or above which is to be commended. Ludford Road, 75 DS0000016868.V326179.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 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. The health and safety of the residents and staff were well managed. EVIDENCE: The manager of the home had a number of years experience in caring for people with mental health needs and the running of a residential home. She had been the registered manager at Middleton Hall Road and had transferred with the service to the current address. The CSCI were in the process of registering her at the current location. Throughout the course of the inspection she demonstrated a good knowledge of the needs of the residents in her care. Relationships between the manager, staff and residents were very good. It was evident throughout that the residents were very comfortable in the Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 22 presence of the manager and had no hesitation in approaching her about any issues. The organisation had had a quality management system in place for some time and they were in the process of updating this. The home had a quality assurance outcome report in place for 2006/2007. This detailed what the home had achieved and what needed to improve. There were regular meetings with staff and residents and several internal audits were undertaken on a regular basis, for example, health and safety and medication. The home also had an equality and diversity plan in place. It was evident throughout the course of the inspection that the home was run in the best interests of the residents and that their input was encouraged. Health and safety in the home were very well managed. Staff received training in safe working practices. There was evidence on site that all the equipment was regularly serviced. All the in house checks on the fire system were up to date, fire training had been carried out and fire drills were carried out at regular intervals. The manager had reviewed the fire risk assessment as required at the last inspection. The environmental health officer had visited the home since the last inspection and no issues had been raised. The recording and reporting of accidents and incidents was appropriate. Ludford Road, 75 DS0000016868.V326179.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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 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 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Ludford Road, 75 DS0000016868.V326179.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 YA9 Regulation 13(4)(c) Requirement There must be risk assessments and management plans in place for any identified risks that residents may be exposed to. There must be written protocols in place for the administration of PRN medication. There must be clear evidence on site that all staff have received all regulatory training with the required updates. Timescale for action 14/02/07 2. 3. YA20 YA35 13(2) 18(1)(a) 14/02/07 01/03/07 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 Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 25 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 Ludford Road, 75 DS0000016868.V326179.R01.S.doc Version 5.2 Page 26 - 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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