Inspection on 25/01/07 for 79 Coriander Close

This inspection was carried out on 25th 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

79 Coriander Close 11/01/06

79 Coriander Close 13/06/05

79 Coriander Close 03/02/05

79 Coriander Close 15/09/04

79 Coriander Close 10/03/04

79 Coriander Close 02/10/03

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, 79 Northfield Birmingham West Midlands B45 0PB Lead Inspector Brenda O’Neill Key Unannounced Inspection 25th January 2007 09:30 Coriander Close, 79 DS0000017156.V327610.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, 79 DS0000017156.V327610.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, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coriander Close, 79 Address Northfield Birmingham West Midlands B45 0PB 0121 457 8257 0121 457 8355 j.knight@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, 79 DS0000017156.V327610.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 11th January 2006 Brief Description of the Service: 79 Coriander Close is a three bedroomed 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 service user bedrooms, a bathroom and toilet and a small staff office. To the front of the house there is off road parking. There is a garden to the rear of the house. The home is not accessible to people who may use a wheelchair as there is no lift or aids and adaptations to assist people with impaired mobility. Fees at the home ranged from £1778.77 to £1891.70 and are based on the individual needs of the residents living at the home. Coriander Close, 79 DS0000017156.V327610.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. During the course of the inspection a tour of the home was undertaken, one staff and two resident files were sampled as well as other care, health and safety and staff training records. The inspector met all the residents and spoke with the manager and two staff members. There was no communication with the residents due to their complex needs, therefore they were unable to comment on the quality of care at the home. Prior to the inspection the manager had returned a completed a pre inspection questionnaire to the CSCI which included additional information about the home. The home had not had any complaints since the last inspection and none had been lodged with the CSCI. What the service does well: There were good systems in place for determining the goals and aspirations of the residents involving the knowledge of the people who have worked with them for some time and influenced by families and friends. All the residents had very comprehensive care plans in place that detailed how staff were to help them meet their needs. The needs of the residents and their care plans were reviewed regularly by staff at the home and by social workers and updated as necessary. There were comprehensive lists of the residents’ likes and dislikes about food, drinks, activities and clothing included in their care plans. A great deal of effort had been taken by staff to include as much information as possible to ensure residents were able to make choices wherever possible. To enable the residents to make decisions about their daily lives staff had developed ways of communicating with them, for example, gestures, body language, objects of reference and BSL adapted signs. Residents’ daily diaries gave a good overview of the well being of the residents and how they had responded to their care. Any missed activities were detailed and the reason why was included. Extensive risk assessments had been undertaken to try and ensure residents were not put at risk when undertaking every day tasks or activities. There was a good range of activities available for the residents to take part in both in the home and out in the community. Contact with the residents’ families was clearly detailed in the residents’ files and the important people in the residents’ lives were identified. How contact was to be maintained was also detailed. Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 6 There were adequate records to show that the health care needs of the residents were being monitored on an ongoing basis and that they saw the appropriate health care professionals as required. Appropriate staffing levels were being maintained and staff received all the necessary training to ensure they were able to care for the residents. 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. The home provided residents with a safe, well maintained, comfortable and homely environment in which to live. What has improved since the last inspection? What they could do better: To ensure the medication system was entirely safe the manager needed to ensure that: All medication prescribed for the residents was 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. As a minimum new staff must have a POVA first check undertaken prior to them commencing their employment to ensure the residents are safeguarded. There needed to be evidence on site that staff had undertaken fire training at the required intervals. Coriander Close, 79 DS0000017156.V327610.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, 79 DS0000017156.V327610.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, 79 DS0000017156.V327610.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: The same three residents had been living at 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 were influenced by families and friends. All the residents had very comprehensive care plans in place that detailed how staff were to help them meet their needs. The needs of the residents and their care plans were reviewed regularly by staff at the home and by social workers and updated as necessary. Coriander Close, 79 DS0000017156.V327610.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 good. 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 any identified risks were to be minimised by staff. EVIDENCE: Two residents files were sampled. Both of the files included very comprehensive care plans. Both files had details of how the individuals’ morning, evening and night time routines were to be carried out and included information about what they were able to do for themselves to ensure they maintained as much independence as possible. The care plans included session plans for all activities that were undertaken with the residents. These included how to let the individual know what activity was planned by using objects of reference and the indicators that would be shown if the individual did not want to take part. There were comprehensive lists of the residents’ likes and dislikes about food, drinks, activities and clothing. A great deal of effort had been taken by staff to include as much information as possible to ensure residents Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 11 were able to make choices wherever possible. For example, one of the residents would choose his drink by smelling the tea and coffee and indicating which one he wanted. Residents were encouraged to prepare their own breakfast and drinks. Comprehensive details of how this was to be enabled by staff were included on the files. 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. To enable the residents to make decisions about their daily lives staff had developed ways of communicating with them, for example, gestures, body language, objects of reference and BSL adapted signs. One of the files included a dictionary of objects and what these meant to the residents so that staff were able to use the objects effectively. 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 missed activities were detailed and the reason why was included. Refusals to partake in activities were detailed showing that staff respected the residents’ rights to refuse. The diaries were being signed by the appropriate authors as required at the last inspection. Extensive risk assessments had been undertaken to try and ensure residents were not put at risk. There were risk assessments in place for such things as choking, self-injurious behaviour, manual handling, bathing, eating out, use of kitchen equipment and all activities. 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. All the risk assessments were regularly reviewed and updated if necessary. Coriander Close, 79 DS0000017156.V327610.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: There were activity plans in place for all residents and copies of these were sent to the inspector with the pre inspection questionnaire. Activities included such things as swimming at the local baths and further afield, ice skating, bowling, walking to the shops, pub outings, use of a snoezelan, using public transport and adult soft play. Daily diaries evidenced that these activities did take place and they also recorded how the residents reacted to the activity and any refusals. In house activities included hand and foot massages, use of the walking machine, use of the sensory room and cooking. Activities were regularly reviewed at the core meetings every month to ensure they were Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 13 suitable and that the residents enjoyed them. Part of the core team meetings was also to discuss how residents had been enabled to make choices and express their preferences. Contact with the residents’ families was clearly detailed in the residents’ files and the important people in the residents’ lives were identified. How contact was to be maintained was also detailed. One of the files included birthday cards that had been purchased for the resident’s family members. The menus at the home were varied and nutritious. The residents’ files included extensive lists of their likes and dislikes in relation to food. Residents were seen to be encouraged to make their own drinks and prepare food as much as they were able. The daily dairies included details of what the residents had eaten and drunk throughout the day. Where there were any issues or risks involved in eating these were clearly detailed in personal files with guidelines for staff as to how the risks were to be reduced, for example, choking. Coriander Close, 79 DS0000017156.V327610.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: The needs of the residents were such that they were very reliant on staff to help them with their personal care needs. The morning and night time routines included in the personal files of the residents were very detailed as to how staff were to assist the residents. There were details of what the residents were able to do for themselves regardless of how small the task may be and of how staff were to assist. Detailed tasks included getting out of bed, bathing, washing hair, oral care and shaving. 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. There was detailed information on the residents files of their past and this included the history of their vision and hearing and at what stage they were at now. The files sampled included health action plans which included evidence of Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 15 regular appointments with opticians, G.Ps, dentists and chiropodists. Where necessary advice was sought from other health care professionals, for example, speech and language therapists who would visit the home and observe residents eat if the staff were concerned. There was ample evidence that staff identified any health concerns and alerted the appropriate health care professionals as needed. For example, one of the residents had been having some falls and staff identified this was possibly due to a health problem and this had been resolved quite quickly. Any health care issues were also discussed and reviewed at the core team meetings. 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. None of the residents were able to administer their own medication. Some issues did arise during the course of the inspection. One resident had recently been prescribed some medication to administered PRN (as and when necessary) however this was not detailed on the MAR (medication administration record) chart and there were no written guidelines in place for the administration of this medication. There was also some paracetamol in the home that had not been entered on the appropriate MAR chart. One lot of medication that was not in the monitored dosage system was audited the balance was correct. However to establish this the previous MAR chart had to be looked at as the balance held in the home had not been entered on the current MAR chart. The manager stated she would address these issues straight away. Coriander Close, 79 DS0000017156.V327610.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 ensure that service users are 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. No complaints had been logged at the home and none had been referred to 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. Due to the complex needs of the residents they were unable to manage their own financial affairs. The organisation was the appointee for all residents. All had individual bank accounts and two managers had to sign to draw money from the accounts. Any amounts over £200 had to be authorised by the organisation. All the money drawn from the accounts was accounted for, receipts were available for all expenditure and records were appropriately signed. Small amounts of money were left accessible to staff ensuring residents had access at all times for anything they may need. The records for Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 17 the money held on site were checked and all the balances were correct. Representatives from the organisation also audited the financial management systems in place at the home. Coriander Close, 79 DS0000017156.V327610.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 that is like a domestic dwelling and therefore was a very homely place for the residents. The home was well maintained and safe and residents were able to find their way around. The pre inspection questionnaire detailed that the bathroom and bedrooms had been decorated and some new furniture had been purchased for the bedrooms. All the bedrooms are of single occupancy and are located on the first floor of the home. All were appropriately personalised to reflect the personalities of the residents. One of the bedrooms had padding fitted to the walls around the bed to prevent the residents from injuring themselves. Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 19 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. On the ground floor of the home was a well furnished and nicely decorated lounge, a sensory room which staff had redecorated to make it more interesting for the residents and they were also waiting to have a spot light fitted. One of the residents was using the sensory room during the course of the inspection and the manager stated they liked the vibrating chair that was in there. Also on the ground floor was a combined kitchen/diner. The table and chairs in the dining area were quite worn and stained and needed to be replaced. There were patio doors leading from the lounge into a large well maintained garden that had seating areas 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, 79 DS0000017156.V327610.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, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A well trained staff team maintained appropriate staffing levels. The recruitment procedures were robust but needed to be applied consistently to ensure the residents were safeguarded. EVIDENCE: Staff turnover at the home is relatively low and only one member of staff had moved since the last inspection and this was an internal transfer to one of the organisation’s other homes. Two new staff had been redeployed to the home and one new support worker had been appointed. The other staff working at the home had been there a considerable amount of time. Bank or agency staff covered any staff absences or vacancies that did arise but the same staff were used, as consistency was very important for the residents. The interactions between the staff and residents were very positive throughout the inspection. There were two staff on duty throughout the waking day and one waking night staff. The home also had an unregistered care manager and a registered care manager that supervised both this home and another in the same Close. Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 21 The recruitment documentation for the new employee was sampled. The file included a photograph, completed application form, proof of I.D and eligibility to work in this country, two written references and a CRB check. However it was noted that the CRB had not been obtained until after the employee had commenced working at the home. The manager and inspector checked the records and further records were sent to the CSCI after the inspection evidencing that this person had been working nights but was supervised at all times by a regular night worker. This issue was discussed with the manager as if this is to happen, as a minimum staff must have a POVA first check undertaken. The manager did comment this was very unusual for the organisation, as they would not normally allow anyone to commence employment without the full CRB check being completed and returned. There was an extensive induction training programme in place for new staff where they undertook training both on and off site. 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. There were one or two omissions on the matrix and these were discussed with the manager. Any staff that had not attended one of the courses or a refresher as required had been nominated for the next course run by the organisation. Six of the nine staff at the home had NVQ level 3 and two others were undertaking this training. Coriander Close, 79 DS0000017156.V327610.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: The manager of the home was present throughout the inspection. She had a lot of experience caring for people with learning disabilities and sensory impairments. Throughout the course of the inspection she demonstrated a very good knowledge of the residents in her care and the running of a residential home. It was evident observing the manager with the residents that she was aware of how to communicate with them and they appeared comfortable in her presence. The organisation has a formal quality assurance system in place. The system includes internal audits on such things as health and safety, individual staff Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 23 audit, finance themed audit and medication audits. The home had a self assessment report for 2006 that had been compiled by the manager which results in an operational plan for the home. The home is also audited by the organisation. 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. All the in house checks on the fire system were up to date and regular fire drills were undertaken. 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. The manager stated that fire training had been undertaken on a team away day but no evidence of this could found. There was evidence on site that the majority of the equipment was regularly serviced with the exception of the gas appliances. This was faxed to the inspector the day after the inspection. The systems in place for accident and incident recording and reporting were appropriate Coriander Close, 79 DS0000017156.V327610.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 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 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 2 X Coriander Close, 79 DS0000017156.V327610.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 YA20 Regulation 13(2) Requirement 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. There must be written protocols in place detailing when any PRN medication is to be administered. The table and chairs in the 01/05/07 dining area must be replaced. As a minimum staff must have a 14/02/07 POVA first check prior to them commencing their employment. There must be evidence on site 14/02/07 that staff have received updated. fire training. Timescale for action 14/02/07 2. 3. 4. YA27 YA34 YA42 16(2)(c) 19 23(4)(d) Coriander Close, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 26 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, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 27 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, 79 DS0000017156.V327610.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!