Inspection on 03/08/07 for Alvechurch Road, 76

This inspection was carried out on 3rd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alvechurch Road, 76 28/08/09

Alvechurch Road, 76 19/07/06

Alvechurch Road, 76 02/02/06

Alvechurch Road, 76 17/08/05

Alvechurch Road, 76 14/12/04

Alvechurch Road, 76 03/08/04

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 Alvechurch Road (76) West Heath Birmingham West Midlands B31 3QW Lead Inspector Gerard Hammond Key Unannounced Inspection 2nd August 2007 09:30 Alvechurch Road (76) DS0000016934.V343540.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 Alvechurch Road (76) DS0000016934.V343540.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. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Alvechurch Road (76) Address West Heath Birmingham West Midlands B31 3QW 0121 258 0887 0121 475 8741 beverley.hayles@fch.org.uk 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) Friendship Care and Housing Association Beverley Hayles Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alvechurch Road (76) DS0000016934.V343540.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 19th July 2006 Brief Description of the Service: 76 Alvechurch Road is registered to provide accommodation, care and support for up to six adults with learning disabilities. The house is a spacious domesticscale property located in the West Heath area of Birmingham, close to shops and local amenities, and well served by public transport. There is off-road parking at the front of the house. Accommodation is provided in single bedrooms, two on the ground floor and four on the first floor, which can be accessed either by the main staircase or by a passenger lift. Downstairs there is a good-sized lounge / dining room, kitchen and separate laundry. There is also an assisted shower room, with w.c. and wash hand basin, and a further separate w.c. Upstairs are two bathrooms (one assisted), both with w.c. and wash hand basins. The office is also situated on the first floor. To the rear of the property is a secure private garden, with a patio and seating area, and lawn edged with planted border. The current range of fees charged by this service is £326.44 - £743.19 per week. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. Information was gathered from a number of places prior to making a visit to the home. The Manager provided the Annual Quality Assurance Assessment (AQAA) for the service and other reports submitted throughout the year. The last inspection report was also referred to. A full day was spent at the home. The Inspector was able to meet with all of the residents, and interviewed the Manager and members of staff. Direct observations and sampling of records (including personal files, care plans, safety records and other documents) were also used to inform this report. A tour of the building was also completed. Thanks are due to the residents, manager and staff for their co-operation and support throughout the inspection process. What the service does well: What has improved since the last inspection? The Manager and staff have worked hard to meet all the requirements made at the time of the last inspection. The kitchen has been refitted, and new furniture bought for the dining room. A new tumble drier has been fitted in the laundry room, and the bathrooms have been redecorated. Some rails have been fitted around the home to help people get around more easily. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 6 The Manager is now registered and has done some more training to help her to do her job better. There is a new plan in place so that everyone knows what is being done to improve the service. 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. Alvechurch Road (76) DS0000016934.V343540.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 Alvechurch Road (76) DS0000016934.V343540.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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is readily available to help people make a decision about whether or not to use this service. As well as this, they have the chance to visit and to stay over, so that they can try the place out for themselves. They get a full assessment of their care needs to make sure that the service can give them the support they need. EVIDENCE: There have been no admissions since the time of the last inspection, and there are currently no vacancies. Most of the people living in this house have been there for several years, and know each other well. As reported previously, appropriate information is available to help a prospective resident to make a decision about whether or not the service can meet his or her needs. Systems are in place to give people the opportunity to visit the home and to stay over, so that they might try out what the service has to offer, before any decision about placement is made. Individual needs are assessed properly, to ensure that support needs can be met. Clear evidence was seen at the last inspection that actual practice backs up the services policy and procedure in these matters. Residents’ personal files were sample checked, and up to date assessments and written contracts were in place as required. Alvechurch Road (76) DS0000016934.V343540.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): 6,7,8 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have very good care plans that include their wishes and their goals, and they are well supported to achieve these in the way that they want. They are actively involved in the day-to-day running of the house, and are supported to make decisions about things that are important to them. EVIDENCE: Previous reports show that care planning and management has been carried out to a good standard in the past. Sample checking of personal files provided clear evidence that this continues to be the case, and that continued efforts are being made to improve on past performance. Files contain detailed personal profiles, with clear guidance about how support should be given. Good efforts have been made to present information in a person-centred way, showing details of things that are important to each person, and seeking ways in which they can be supported to achieve their goals. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 10 One person has a particular concern about road safety in the neighbourhood. She has been supported to raise this matter with the local Member of Parliament, and the correspondence relating to her attempts to get improved crossing facilities was seen. Another resident is being supported to trace a long-lost sister. Staff have dealt with this very sensitively and are exploring a range of options to achieve this. Care plans are supported with detailed risk assessments, and there are clear links between the two, so that it is easy to track important information. It was noted that these are now indexed, as recommended at the last inspection. Conversations with the Manager show that the service continues to have a positive attitude to risk management, viewing this as an opportunity for learning and personal development, while seeking to minimise the likelihood of anyone coming to harm. People are actively encouraged to be as independent as their individual abilities allow. Residents were seen taking responsibility for domestic tasks including vacuum-cleaning and washing up. Those who go out to centres and colleges prepare their own packed lunches. Staff were observed supporting people to make choices about what they wanted to eat and drink. Residents have their own rota for doing jobs around the house, and are very good at reminding each other whose turn it might be. They have their own notice board in the hallway, and this includes photographs of staff that get changed at each shift, so that they know who will be on duty. Residents’ meetings are facilitated by an independent advocate, and staff only attend for part of the meeting if invited. It was recommended that dates for these meetings are scheduled in advance, to ensure that they take place on a more regular basis. Each person has a designated key worker, who is responsible for keeping a record of a one to one meeting each month. In this way, care plans and goals are being kept under constant review, and can be updated regularly, as required. Alvechurch Road (76) DS0000016934.V343540.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): 12,13,14,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People enjoy taking part in activities that they value. They are well supported to be part of their local community and to keep in touch with their families and friends. They have a balanced and nutritious diet and enjoy their food EVIDENCE: People continue to access local colleges and centres for structured activities during the week. As previously reported, one person has an Autistic Spectrum Disorder and does not cope well with strange or crowded places, so he is supported to access community facilities by staff according to his wishes. The Manager reported that she is actively encouraging residents to consider more regular evening activities, so as to broaden their opportunities. However, she said that most are happy to relax at home during the evenings, particularly if they have had a busy day at college or the day centre. In addition to the multi-channel TV, there is a range of games and tabletop activities that people can use if they so wish. Residents have continued to take an active interest in Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 12 developing the garden, which they clearly enjoy. In addition to the borders, pots and baskets that they help to look after, one resident was particularly proud to show the inspector the new vegetable patch that has been established since the last inspection. She said that she was looking forward to eating some of the things they had grown, in the near future. Records show that people access local shops, pubs and clubs when they wish. Some people are able to travel independently on public transport, following appropriate risk assessment and training. As mentioned earlier in this report, one resident is active in promoting better road safety in the local community, campaigning through the local MP for improved crossing facilities to local shops. Two of the residents returned recently from a holiday in Scotland, which they said they enjoyed very much. Plans are in place for others to go away in the near future according to what they want to do. One resident said she is planning some day trips with her key worker, because she does not like to be away from home for long. Another is looking forward to taking a holiday with his mother in the next few weeks. Records show that residents are supported to keep in touch with people that are important to them, according to the wishes of all those involved. Some people visit their relatives at home and stay over regularly. As reported earlier, one person is being supported to trace a relative she has not seen since childhood. Three of the residents have “befrienders” whom they see on a regular basis. They are supported to keep in touch with them and make arrangements to meet independently. In addition to the independent advocate who facilitates their tenants’ meetings, one person also attends a regular social event organised by a local advocacy group. Everyone in the house is actively encouraged to take responsibility for as many things as they are able, so as to enhance their personal independence. These include doing jobs around the house, looking after their rooms, and assisting staff doing health and safety checks in the home. Food stocks were examined: these were plentiful and included fresh produce. Residents confirmed that they take an active role in grocery shopping, and that they choose what they are going to eat on a day-to-day basis. The small size of the home facilitates this. Staff are working hard with residents to promote healthy eating in conjunction with taking exercise, to try and maintain and develop better health and general well being. Alvechurch Road (76) DS0000016934.V343540.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 & 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are well looked after and receive support in ways that suit them personally. Practice in the home ensures that people get the right amount of medication at the right time and they are well supported to stay fit and well. EVIDENCE: Direct observations of people’s clothing and grooming provide clear evidence that residents receive a good standard of personal care. The staff team in this home is well established, so people living and working there know each other well. Both are very comfortable in each other’s company and speak fondly about each other. Care plans are well written, and it is clear that staff have good knowledge and a good understanding of the needs and wishes of the people in their care. As recorded above, each person has a designated key worker. They keep a record of a monthly meeting to show how people’s plans and goals are being kept under review and acted upon. Personal files show evidence of the involvement of a range of professionals including GP, consultants, community nurse, dentist, chiropodist, optician, Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 14 physiotherapist and others. Detailed health action plans are in place, though it was noted that some need to have clear goals specified. This is a work in progress. Staff are pro-active about seeking advice and support for residents so as to address any identified issues. It has been noted that some residents’ mobility is showing signs of deterioration, so referrals were made to a physiotherapist. Following an assessment, a programme of exercises has been devised and staff are supporting people sensitively to ensure that they carry these out. Residents were clearly fully involved in this, and were able to tell the inspector why their new programmes were necessary, and how they were getting along with them. Medication records were reviewed. Practice in this area is generally very good. The Medication Administration Record (MAR) was completed in full. A number of “secondary checks” are in place, to ensure that the risk of any errors is minimised. There is a witness sheet, signed by a second member of staff to confirm details recorded on the MAR. The shift handover sheet includes an audit of medication, and the Manager also conducts her own audit periodically. The Medication file contains a general dispensing protocol, and all PRN (“as required”) medication is supported by a written protocol. Sample signatures of all staff responsible for administering medicines are included, and individuals’ records contain a recent photograph and copies of prescriptions. The medication cupboard was inspected: this was clean, neat and tidy and secure, as required. Two of the residents have suffered bereavement in recent months. Conversations with staff showed that this has been dealt with sensitively and the Manager reported that they had sought professional advice regarding the best way to give support through these difficult times. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 15 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. People are confident that any issues they have are taken seriously, so that their concerns are listened to and acted upon. Precautions are taken to ensure that residents are protected from abuse, neglect or self-harm. EVIDENCE: No complaints have been received in respect of this service since the last inspection. Appropriate policies and procedures are in place regarding making complaints and the protection of vulnerable adults from abuse. Residents know that they have a right to complain, and said that they were happy to raise any concerns they have with either the Manager or other members of staff, because they know what they say is taken seriously. They also know that if they wanted to complain but did not want to go to a member of staff, that they have a postcard they can send to head office. Someone from outside the home will then come and see them to discuss their concerns. The organisation has a very positive complaints culture and is particularly proactive in this area. The Manager was able to show that the complaints file now also contains a version of the policy and procedure on DVD. As mentioned above, tenants’ meetings are facilitated by an independent advocate, and staff only take part by specific invitation. In this way, people know that they have an open forum in which they can discuss any issues of concern in confidence. Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 16 The adult protection policy is linked to local multi-agency guidelines, and now also includes a DVD provided by the local authority. The Manager said that this had been shared with the residents to increase their understanding of these matters, and they had signed to say that this had been done. Staff have received training in adult protection, and recruitment procedures are appropriately robust, including Criminal Records Bureau and “POVA First” checks as required. Alvechurch Road (76) DS0000016934.V343540.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): 24,26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house is well maintained so that residents enjoy the benefit of living in a safe, comfortable, and welcoming home environment EVIDENCE: The residents at Alvechurch Road enjoy the benefit of living in a house that is both homely and comfortable. The building is domestic in scale and is decorated and furnished throughout to a good standard. People’s rooms are individually styled and interiors reflect the wishes and the character of the occupant. Personal possessions and effects are very much in evidence. The main living room has been redecorated and a new dining table and chairs bought. The Manager advised that she is seeking to identify resources to buy new lounge furniture. It has been noted that some of the residents are beginning to experience some difficulties getting out of armchairs, due to deteriorating mobility. A new television with “free view” channels has also Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 18 been provided in this room. The upstairs bathroom has been redecorated and re-equipped, and grab rails fitted at the head of the stairs. Residents and staff are very pleased with their newly re-fitted kitchen. Residents said that they chose the units and colour scheme and are very happy with the end result. A new tumble drier has also been installed in the laundry room. Action taken to deal with the musty smell that has been something of a longstanding issue in the downstairs shower room seems to be containing the problem for the time being. It is recommended that the flooring be replaced when resources allow. As mentioned above, residents take a pride in their garden and enjoy spending time in it when the weather permits. They help to tend the borders and hanging baskets and have established a vegetable plot, with the assistance of members of the staff team. A previous requirement that staff ensure the ashtray in the garden is emptied after use had been met on the day of the inspection visit. The house is generally well maintained, and kept clean and tidy with good standards of hygiene upheld. Alvechurch Road (76) DS0000016934.V343540.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): 32,33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a well trained and supported team of staff that know them well and understand their needs. EVIDENCE: The majority of the staff team at Alvechurch Rd. has worked in the home for several years, so people living there benefit from consistency and continuity of care. Direct observations provided clear evidence that staff know what they are doing, and understand the support needs of the people in their care. Information provided by the Manager shows that 75 of the team holds qualifications at NVQ level 2 or above. Newly appointed staff now also do training under the Learning Disability Awards Framework (LDAF). Sample checking of staff files showed that all documents required were in place, demonstrating an appropriately robust recruitment process and providing evidence of this being put into practice. The organisation operates a rolling programme of training for all its employees. The Manager was able to produce the training plan recently submitted to head office in order to inform them of the staff team’s training requirements over the coming months. It was Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 20 recommended that the training information held on individual staff members’ files be transferred to a spreadsheet, so that this can be monitored more easily and effectively in the future. This record should show (for each member of staff) training completed and qualifications gained (with dates), highlight any gaps (e.g. when “refreshers” are due) and show when outstanding training is to be delivered. Holding this information in this way should make it easier to update the training plan and to monitor progress. It is also recommended that staff have access to specific training for working with people who have autistic spectrum disorders. Records show that staff meetings generally take place on a monthly basis, and that formal staff supervision is up to required standards. Staff also now receive annual appraisals (PDR personal development review) in line with the home’s own service development plan. Conversations with staff team members demonstrated a very positive attitude to the work they do, and a high level of commitment to the people in their care. Feedback from one of the residents’ friends, who visits regularly, said “I always find staff helpful and friendly” and “(N) is cared for by staff who are competent, conscientious and caring”. Alvechurch Road (76) DS0000016934.V343540.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, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Alvechurch Road benefit from living in a home that is well run. Their views are taken into account and inform plans to develop the service, so that they can get the support they need in the way they want it. Tests of essential equipment in the home must be carried out consistently, so as to ensure that people living and working there remain safe at all times. EVIDENCE: The Manager is qualified to NVQ level 4 and has now also recently completed the Registered Manager’s Award. The certificate for this was seen during the inspection visit. A requirement to register with CSCI has now been met. The development of the service for the benefit of the people using it remains her high priority, and to this end the staff team has produced a Development Plan Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 22 focussing on four key areas. These are value for money, customer excellence, sensible growth and valuing the workforce. As previously reported, the style of management in the home remains open and inclusive, with residents and staff being encouraged to take responsibility and to play an active role in how the place is run. Both report that the Manager is approachable, and that they feel confident raising any issues of concern with her. The organisation has a good track record of asking people who use their services what they think. It is intended that the service development plan will be reviewed each quarter, in order to keep it “on track”. It is recommended that systems for quality assurance and monitoring are formalised so that there is a clear “audit trail” of how people have been consulted, and how their views have been taken into account in planning and service development. This should be reported on annually, and the outcome shared with all interested parties. There are already a number of examples of good practice in this area (e.g. key worker monthly reviews, independently facilitated tenants’ meetings, development plan etc.), so this recommendation is more about bringing these elements together and consolidating practice than anything else. On the day of the inspection visit, copies of all reports required under Regulation 26 (Care Homes Regulations 2001) were not available. Some of these were subsequently forwarded, and the Manager confirmed that she receives regular visits and good support from her line manager. These visits should be monthly and unannounced, and a written report should be made available on each occasion. It was suggested that a report template be placed on the home’s computer so that notes of the meeting could be more easily completed, perhaps while feedback is given to the Manager at the end of each visit. Safety records were sample checked. The fire alarm and emergency lighting systems had been serviced, together with the home’s fire fighting equipment. Fire training has also been delivered. It was noted that there were a number of gaps in the records for testing of the fire alarm and emergency lights. These must be tested regularly, and a full written record of tests maintained. It was recommended that the “read and sign” sheets for fire risk assessments and related information be reviewed, to act as a reminder for staff and to ensure that they are kept up to date. Checks of fridge and freezer temperatures had been carried out as required. The COSHH cupboard was secure. Alvechurch Road (76) DS0000016934.V343540.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 3 2 3 3 X 4 3 5 3 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 3 28 3 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 4 4 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 3 3 3 3 X X 2 X Alvechurch Road (76) DS0000016934.V343540.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 (4) Requirement Ensure that essential equipment is tested regularly to show that it is in good working order, in order to keep people living and working in the home safe from harm. Timescale for action 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA19 YA35 YA39 Good Practice Recommendations Set clear goals in individuals’ health action plans, so that it becomes clear what is working and what is not. Transfer staff training information to a spreadsheet, so that it is easier to monitor and update. Formalise current practice for seeking residents’ views on service quality and produce a written report, so that it is possible to see clearly how their views have been taken into account in service review and development. Alvechurch Road (76) DS0000016934.V343540.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 Alvechurch Road (76) DS0000016934.V343540.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. 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