Inspection on 13/09/07 for 88 Church Lane

This inspection was carried out on 13th September 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

88 Church Lane 04/12/06

88 Church Lane 19/12/05

88 Church Lane 03/12/04

88 Church Lane 14/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Church Lane, 88 Handsworth Wood Birmingham B20 2ES Lead Inspector Julie Preston Key Unannounced Inspection 13th September 2007 11:00 Church Lane, 88 DS0000030401.V338614.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 Church Lane, 88 DS0000030401.V338614.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. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Lane, 88 Address Handsworth Wood Birmingham B20 2ES 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) 0121 554 7710/8858 F/P 0121 554 7710 churchlane@sense.org.uk www.sense.org.uk Sense, The National Deafblind and Rubella Association Mrs Christine Hannah-Smith Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration for 5 younger adults (under 65 years of age), categories learning disability and sensory impairment 4th December 2006 Date of last inspection Brief Description of the Service: 88 Church Lane is a large spacious house that has been adapted to meet the needs of people with visual and hearing impairment and associated learning disabilities. The home is located in the Handsworth Wood area of Birmingham. Sense are the homeowners and the care providers. The home is registered to provide care and accommodation for five adults. The accommodation comprises of a large communal lounge a separate dining room and large kitchen. There is an additional quiet lounge on the first floor and a sensory room. All five bedrooms have ensuite bathrooms. One bedroom is on the ground floor and four are on the first floor. An office and staff sleep in facilities is located on the second floor. There is off street parking at the front of the house. The home has a large rear garden with a decked terrace and steps leading to a lower grass area. Information is shared with people who live in the home by use of objects of reference and tactile markers to enable individuals to make choices and map out their location within the home. Fees charged to service users range from £1600 to £18000 a week, to which individuals pay a set amount from their Department of Works and Pensions benefit. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. Two service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. People who live in the home are given lots of support to help them communicate and find their way around their home. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. There are lots of opportunities for people to make decisions about their lives so that they do things for themselves, go out often and have a chance to practice their skills. People are provided with meals that they like and have chosen. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 6 There are good procedures to listen to people and keep them safe from possible harm. Staff know people who live in the home well and are friendly to them. People said, “They’re really good here” and “I like all of them”. Regular health and safety checks are made so that equipment is well looked after and safe for people to use. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: The home has a statement of purpose and service user guide, which is made available to people who live there and their relatives. There have been no new admissions since the last inspection and there are currently no vacancies. There are systems in place to ensure that individuals’ needs are assessed before they move into the home and that people have an opportunity to visit and stay over prior to making any decisions about whether to move in. One person commented that he had had lots of visits to the home before moving in to help him decide whether to live there. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems of care planning and risk assessment in place to enable peoples’ needs to be understood and met. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: The care plans for two people were sampled. Both contained information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. The care plans had been reviewed within the last six months to ensure they continue to be relevant to individuals’ needs. Staff had signed care plans to confirm that they had read them, which should make sure that people receive the care they need consistently. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 10 The home has a Practice Development Worker (PDW) who works part time to support the staff team with the development of peoples’ care plans and risk assessments. It was noted that the staff team are actively contributing to devising and reviewing care plans, which was recommended at the previous inspection. Some people who live at the home have specific needs with regard to the way they communicate. Speech and Language therapy guidelines were observed which detailed the most effective way to communicate with people; staff were seen to follow this guidance by using objects of reference to help individuals make decisions about activities that had been planned. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. Risk assessments sampled had been reviewed on a regular basis. People who live at the home need assistance to manage their money. There are systems in place to record individuals’ income and expenditure, which are audited for their ongoing protection. A financial audit was conducted by SENSE National Finance Team this year. No issues were identified for action, which indicates that peoples’ money is being safely looked after. From observation of two peoples’ records, it was evident that they make choices about what they spend their money on, such as personal items, haircuts, clothes and leisure pursuits. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: People’s activity preferences had been recorded in their plans of care. Daily records were sampled to check that people had regular opportunities to take part in things they enjoy doing. Records showed that people undertake many activities such as going to church, horse riding, college courses, shopping, local walks, household tasks and music sessions at a nearby Recording Studio. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 12 Some records had not been completed in sufficient detail to describe what people had been doing at weekends and during the evenings. It is recommended that records be maintained so that people who live in the home continue to have access to a range of activities that meet their preferences as part of a meaningful lifestyle. One person talked about some of the things he likes doing and said, “I go to church a lot and help there. If I want Talking Books, I get them. I do what I want when I want to”. The inspector observed the handover between staff part way through this visit. The staff team discussed the responses of people living in the home to the activities they had taken part in during the morning, which had also been recorded. The staff team confirmed that this was a useful process as it enabled them to review whether people had enjoyed planned activities or not. Monthly core team meetings are held between staff to discuss peoples’ responses to activities and to plan new ones so that each person has an opportunity to do things they enjoy. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about peoples’ relatives birthdays, so that cards and presents could be sent. The home has a visitor’s policy and the manager commented that relatives have regular contact either by telephone, email or in person. The staff team have considered additional ways in which people can keep in touch with their relatives, such as a web cam for a person who’s relative lives a long way from the home. This is considered good practice. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts and soft consistency meals, which is reflective of service users cultural and healthcare needs. The inspector had lunch with the people who live in the home. Staff offered sensitive support to individuals that require assistance with eating to promote both their dignity and independence. It was evident that people had enjoyed their meal. One person was assisted to use a new jug to pour a drink so that he could do so independently. The person said he was pleased with this. Food shopping is done online although people have opportunities to buy such items as bread, milk and other day-to-day items from a nearby supermarket. The menus sampled were reflective of individuals recorded food preferences. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to meet peoples’ personal and health care needs. Medicines management is not always robust, which could lead to peoples’ needs not being met. EVIDENCE: Two personal and health care plans were sampled at this visit. There was some good information about individuals’ personal care needs and preferences, which staff clearly understood so that people receive care in a manner they need and like. Both male and female staff are employed, which is reflective of the gender of the current group of people living in the home. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 14 Financial and daily records showed that people shop for their own toiletries and clothes and use local hairdressers and barbers, with the support of staff as part of their regular personal care routines. Records showed that people have regular appointments with healthcare professionals and the outcome of this contact had been documented so that staff had accurate information about individuals’ state of health. There was written evidence that peoples’ vision and hearing is reviewed on a regular basis and that their weight is monitored where this is assessed as being important to their health and well being. The home has contracts with the audiology and optometrist services at Selly Oak Hospital as well as Speech and Language Therapists and Behaviour Support Teams so that people have access to advice and support from healthcare professionals in accordance with their needs. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medication was observed to be securely stored in a locked cabinet and it was considered positive that staff had received training in the safe handling of medicines to further safeguard service users health and well being. Where people are prescribed medication on an “as required” basis, written protocols were in place to guide staff as to when they should be given. The home has a medicines policy, however this had not been followed for the period sampled during this visit. The quantity of medicines received for three people had not been entered onto the medication record or the record signed by the staff member responsible for receipt. This would not enable someone auditing medicines to determine that records of administration were accurate. On one medication record it was noted that a person had been on “social leave” and had not received their medication as it was seen to remain in the blister pack. There was no explanation on the record to describe why the “social leave” had prevented the person from receiving their prescribed medication. A bottle of olive oil was observed which, it was reported was used for one person. There was no entry on the medication record to describe the circumstances under which the oil should be used, the frequency or dosage or when the oil had been given. It was not possible to establish how old the bottle of oil was or when it had been opened. These issues need to be addressed so that people receive their medication safely and maintain good health. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 15 Church Lane, 88 DS0000030401.V338614.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: There have been no complaints made about the home since the last inspection. A log of complaints is maintained that records the nature of the complaint and the action taken in response. Information received before this visit on the Annual Quality Assurance Assessment stated that SENSE has a Complaints free telephone line, which can be accessed by anyone, 24 hours a day. Information about the complaints procedure is made available to families and friends in the statement of purpose and service user guide. This is reflective of the needs of the majority of people living in the home as they have complex communication needs and are reliant on relatives to raise concerns or complaints on their behalf. One person did comment that he knew he had the right to complain and clearly understood how to do so. Staff have completed training in the protection of vulnerable adults and the management of challenging behaviour and Non-violent Physical Crisis Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 17 Intervention training, which should enable them to safeguard people who live in the home. The staff members spoken to by the inspector said they would always report any suspicion of abuse so that people were protected. Systems are in place to safeguard the monies of people living in the home. Staff were observed to check financial records at the shift handover. The registered manager demonstrated effective knowledge of the Mental Capacity Act 2005. This Act provides a statutory framework to empower and protect vulnerable people who may not be able to make their own decisions. An up to date inventory of peoples’ belongings is maintained so that staff can keep track if anything goes missing and look after peoples’ possessions. Recruitment records sampled showed that a robust procedure is followed for the ongoing protection of people living in the home. Church Lane, 88 DS0000030401.V338614.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, 26, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely, comfortable, safe and clean environment that meets their needs and promotes their independence. EVIDENCE: Church Lane is a spacious, detached house situated in the Handsworth Wood area of Birmingham. The premises are in keeping with others in the vicinity and are not distinguishable as a care home. Local amenities include public transport links, shops, pubs and restaurants and places of worship. This is important for the people who live in the home as they make regular use of community based resources. The home has been adapted to meet the needs of the deaf/blind people who live there. Good use has been made of colour contrasting on doorways to assist people to orientate around their home. The staff team have promoted a Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 19 communicative environment by placing objects of reference and tactile markers in key places to help people locate rooms and equipment. Shared space in the lounge, kitchen and dining room were free from clutter that could create difficulties for people with a visual impairment, whilst moving around. The kitchen had been refurbished and a new dishwasher and freezers purchased. New furniture and flooring had been provided in the dining room and lounge, all of which contributes to a more pleasant environment for people to live in. Each person has his or her own bedroom, with en suite facilities. The bedrooms observed at this visit were clean and well furnished and decorated. One person said, “I love my room. I have a reading magnifier to help me with my books”. Attention had clearly been made to cleanliness and hygiene in the home. There were adequate hand washing facilities, personal protective equipment for staff so that the risk of the spread of infection could be reduced and there was no evidence of poor cleansing routines. Control of Substances Hazardous to Health (COSHH) products were securely stored for the protection of people living in the home. Church Lane, 88 DS0000030401.V338614.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, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: From observation of staff interacting with people who live in the home it was evident that they have formed friendly and respectful relationships with them. One person made positive comments about the staff team saying, “They’re really good here” and “I like all of them”. Staff responded well to prompts by people who live in the home. For example, a person who clearly indicated that they wished to have a drink was immediately supported to do so. Another person was sensitively assisted with personal care by a staff member who noticed that a change of clothing was needed after lunch. Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 21 The staff rota sampled showed that both male and female staff are employed, which is consistent with the gender of the resident group and that sufficient staff are on duty each day to meet peoples’ needs. The home has a rolling programme for both mandatory training and that, which is relevant to the individual needs of people living in the home, such as managing challenging behaviour and deaf/blind awareness. Observation of staff training records and discussion with some staff members identified that training opportunities continue to be offered on a regular basis. To ensure that people are supported by a qualified staff team at least 50 of staff should achieve an NVQ in care. Information received in the Annual Quality Assurance Assessment stated that 90 of the current staff team have either achieved or are working towards this qualification. From discussion with staff it was evident that they have good understanding of peoples’ needs. Staff talked with confidence about the agreed strategies in place to support people to maintain their independence and manage their behaviour, which was consistent with information in individuals’ plans of care. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. The checking of staff files showed that staff receive formal supervision approximately every two months to offer them the support they need to carry out their work and to receive feedback on their performance. Church Lane, 88 DS0000030401.V338614.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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and peoples’ health and safety is promoted and protected. EVIDENCE: The home has a registered manager, who has achieved her Registered Managers Award and NVQ Level IV in care. It was evident, from discussion with the manager that she has kept up to date in developments in the social care field, for example the new Mental Capacity Act and is committed to creating positive outcomes for the people who live at Church Lane. Quality assurance systems are in place. A representative of the registered provider visits the home on a regular basis to report on the standard of care Church Lane, 88 DS0000030401.V338614.R01.S.doc Version 5.2 Page 23 provided of which reports are made available to the home and CSCI. The most recent report was observed during this visit. The representative had spent a lot of time talking to a person about his views of the home and recommended actions to be followed up by the staff team. From discussion with the manager and staff team, it was evidenced that the actions had been completed. This indicates that people who live in the home are being listened to and included in service development. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. Each person has a fire safety plan that describes how to assist them to evacuate the home safely in the event of an emergency. A report made by West Midlands Fire Service in August 2007 made one reference to an area of deficiency, which at this visit was noted to have been complied with. Staff have completed fire training to help them understand the importance of fire safety. One member of staff talked through the procedure for evacuation and knew what to do in the event that a fire exit was blocked. Fire drills had been conducted on a regular basis to enable staff and people who live in the home to practice evacuation in the event of an emergency; each drill had been recorded. Hot water temperatures are checked and recorded to ensure that they do not pose a scalding risk to people. Staff have undertaken health and safety and infection control training, which should ensure a safer environment for the people who live in the home. Church Lane, 88 DS0000030401.V338614.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 3 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 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 3 X Church Lane, 88 DS0000030401.V338614.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 Medicines received into the home must be entered onto the medication record so that effective auditing can take place for the ongoing protection of people who live there. People must receive their medication as prescribed and codes entered onto medication records must be explained in writing so that the record clearly demonstrates whether the person has received their medication, or that other action has been taken in response to circumstances where medication has not been given. Homely remedies must be linked to a procedure for agreed administration and a record maintained when the remedy is administered. Timescale for action 20/10/07 2 YA20 13(2) 20/10/07 3 YA20 13(2) 20/10/07 Church Lane, 88 DS0000030401.V338614.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. 1 Refer to Standard YA13 Good Practice Recommendations Consideration should be given to recording activities at weekends and during the evenings so that it can be determined that people are leading a meaningful lifestyle. Church Lane, 88 DS0000030401.V338614.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. 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