Inspection on 13/12/06 for Charles Davies House

This inspection was carried out on 13th December 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charles Davies House 07/10/08

Charles Davies House 09/01/06

Charles Davies House 05/07/05

Charles Davies House 17/02/05

Charles Davies House 25/05/04

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

CARE HOME ADULTS 18-65 Charles Davies Hse (Hock) 388 Lodge Road Hockley Birmingham B18 5PW Lead Inspector Brenda O’Neill Unannounced Inspection 13th December 2006 09:30 Charles Davies Hse (Hock) DS0000016862.V323503.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 Charles Davies Hse (Hock) DS0000016862.V323503.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. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charles Davies Hse (Hock) Address 388 Lodge Road Hockley Birmingham B18 5PW 0121 523 8880 F/P 0121 523 8880 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mind in Birmingham Ms Cheryl Marie Yardley Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (13) Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection January 9th 2006 Brief Description of the Service: Charles Davis house consists of three units that can accommodate up to 13 younger adults with enduring mental health issues. Focus Housing Association owns the building and MIND in Birmingham provides the care and support. The home is located within a residential area of Birminghams inner city, approximately two miles from the city centre. The home is close to shops, bus services, a post office and a medical centre. Two of the houses provide single rooms and a communal lounge and dining area for up to nine people. The other unit consists of four bed-sits, including a kitchenette and bathroom. The aim of Charles Davis House is to provide support and training to the residents in order that they can progress onto either independent living or supported living. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out over one day in December 2006 by one inspector. During the course of the inspection a tour of the building was carried out and two empty rooms were seen. Two resident files were sampled as well as other care, staff training and health and safety records. The inspector spoke with the manager, service manager, two staff members and six of the eleven residents. Prior to the inspection the manager of the home had returned a completed a pre inspection questionnaire to the CSCI which gave some additional information about the home. What the service does well: Prospective residents were fully involved in the pre admission assessment process that ensured their needs could be met by the home. Individuals considering living at the home could have extensive introductory visits to assess what the home could offer and to get to know other residents. Residents were fully involved in drawing up their own care plans and risk assessments. They made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. Residents were supported to have an independent lifestyle which the home encouraged and supported them to achieve without undue pressure. Their rights and responsibilities were recognised in their every day lives by staff. The personal and health care needs of the residents were being met and residents were supported and encouraged to take responsibility for these areas of their lives. The relationships between the staff and the residents were very good and the atmosphere in the home was very relaxed giving the residents the confidence to raise any concerns. Staff turnover at this home is very low which is very good for the continuity of support offered to the residents. Relationships between the staff and residents were very good and all the residents spoken with were very happy with the staff team. Comments received from residents included: ‘I get on well with the staff.’ ‘Staff really care they are very understanding.’ ‘They do help if you want it.’ ‘Staff are o.k. They help if needed.’ All staff had undertaken a range of training related to mental health issues including, self harm, voices and valuing the journey to recovery, ensuring they had the appropriate skills to support the residents at the home. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 6 The home offered residents a well maintained, clean and homely environment in which to live. The health and safety of the residents and the staff were well managed. What has improved since the last inspection? What they could do better: Essential lifestyle plans could be further improved to show that where the aims or goals of the individual had not been achieved the reasons why and what actions were to be taken to improve on this. All residents must have in place a risk assessment and management plan that includes details of how staff will know when the residents’ mental health is relapsing and how this is to be managed. To ensure the system in place for the management of medication is entirely safe the manager needed to ensure that regular staff drug audits were undertaken before and after a drug round to ensure the competency of staff. Also all medication that has not been returned to the pharmacist must be included on the MAR charts. The manager needed to ensure that staff received regular updates for all their mandatory training so staff had the necessary current knowledge to be able to work safely. There must be a system in place for continually monitoring the quality of the service offered at the home based on seeking the views of the residents. The outcomes of the quality monitoring must result in an annual development plan for the home stating how the service offered is to be further developed. Charles Davies Hse (Hock) DS0000016862.V323503.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. Charles Davies Hse (Hock) DS0000016862.V323503.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 Charles Davies Hse (Hock) DS0000016862.V323503.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, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents were fully involved in the pre admission assessment process that ensured their needs could be met by the home. EVIDENCE: The file for the resident most recently admitted to the home was sampled. It included evidence that an extensive assessment had been carried out prior to admission. The assessment included information gained from other agencies, the staff at the home and the individual themselves. The referral form had been partially completed by the person to be admitted to the home and included information about their aims and goals in life. The file also evidenced that there had been extensive introductory visits to the home prior to admission and several overnight stays had been included. This gave the individual the opportunity to assess what the home could offer and get to know the other residents. During these visits staff were able to further assess the needs of the individual and ensure the home were able to meet them. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 10 On admission to the home a licence agreement was signed by the residents which detailed the room to be occupied, the fees to be paid and all other relevant information in relation to the terms and conditions of their stay. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were fully involved in drawing up their care plans. They made decisions about their lives on an ongoing basis and were made aware of the risks involved. Management plans needed to be in place for the relapse of all the residents’ mental health to ensure staff knew what they were to do should this happen. EVIDENCE: Residents at the home were fully involved in drawing up an essential Lifestyle Plan (ELP) that identified their needs and how staff were to help support them meet these needs. Information was gathered from a self assessment which residents were asked to complete themselves. This included what the individual wanted to achieve, what had helped them in the past, what skills they thought they had and what they wanted to improve. The ELPs included both the long and short term goals of the individuals in the home with corresponding action plans as to how these were to be achieved. Achievements were being documented to a degree and monthly evaluations were being Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 12 carried out in most cases. However one of the files sampled had no recent monthly evaluations and it could not be determined how far the individual had got in reaching the documented goals. As at the last inspection the ELPs could be further improved to show that where the aims or goals of the individual had not been achieved the reasons why and what actions were to be taken to improve on this. There were numerous risk assessments in place on the files sampled. These included evidence that the residents had been involved in drawing them up and that they agreed with them. Areas detailed included such things as smoking, suicide, aggression, neglect and returning late to the home. All the risk assessments included the triggers, early warning signs and the action to be taken. It was noted that one of the files sampled did not have a management plan in place for the relapse of the individual’s mental health. The manager stated that they were waiting for this from the social worker however the person had been in the home for some time and staff needed to be made aware of how they would know if the person’s mental health was relapsing and what they were to do about it. Residents in the home made decisions about their lives on an ongoing basis and were very involved in running their lives as they wanted. They were fully involved in drawing up their ELPs and deciding what they wanted to do and how staff would need to support them. They were fully involved and aware of the risk assessments in place for them for their protection. Residents made decisions on a daily basis about what courses they attended, if they needed medical treatment making their own appointments where they were able, how they spent their leisure time, what they had to eat and whether they contributed to writing their own daily records. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported to have an independent lifestyle which the home encouraged and supported them to achieve without undue pressure. Their rights and responsibilities were recognised in their every day lives. EVIDENCE: There was ample evidence in the home that residents followed an individual lifestyle and that opportunities for personal development were encouraged. The whole aim of the home was to support and encourage residents to move on to more independent living. It was evident that all the residents were at various stages in this process. The residents spoken with were very happy that the staff at the home allowed them to move at their own pace towards this. Some of the residents had work placements at places such as garden centres, some attended colleges, day centres or employment preparation units. One resident spoken with stated they had attended a retail course but this had Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 14 finished but he was helping out at a local shop. Other residents stated they went to a centre where they were doing computer skills, art and speech. Residents were also able to take part in the same training as staff if they wished. Whilst at the home residents were encouraged to develop skills in cooking, laundry, cleaning and how to budget their money. The residents used many of the local facilities including health care facilities, post offices, shops and pubs. The majority of the residents were able to use public transport independently. Staff escorted those that could not. Some of the residents made regular visits to their families, friends and partners in the local community. Staff went out with the residents for meals or a drink and a game of pool. Some of the residents had taken an annual holiday others preferred day trips and this had been arranged either by them or with the help of staff. The residents’ rights and responsibilities were recognised on a daily basis. Residents told the inspector there were no rules really but you were asked not to smoke in your bedroom or the no smoking lounge. All residents spoken with confirmed they had keys to their bedrooms and the front door and that staff did not enter their rooms without permission. Residents spoke to the inspector about taking responsibility for cleaning their own rooms and their own laundry but if they needed help from staff they asked and it was given. All the residents handled their own money but again systems were in place to help any resident with budgeting where necessary. All the residents spoken with were happy with the catering arrangements at the home. They had the choice of catering for themselves fully or partially and they were given money to enable them to do this. All residents prepared their own breakfasts and the majority their own lunch. There was a menu for the main meal in the evening but if residents did not like what was on this they could choose to have something else cooked for them or cook something themselves. All the residents were involved in some cooking, with staff support, particularly over the weekends. The residents who occupied the bedsits were fully self catering. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 15 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. The personal and health care needs of the residents were being met and residents were supported and encouraged to take responsibility for these areas of their lives. EVIDENCE: The assistance with personal care needed by the residents was minimal it was mainly prompting by staff to ensure their personal hygiene was to an acceptable standard. Any encouragement and prompting needed was clearly detailed in the ELPs. There was good documented evidence that both the physical and mental health care needs of the residents were being met. Residents spoke to the inspector about being encouraged to make their own appointments at the doctors, dentists and so on and that they were able to use the office phone for this. If they did not feel confident enough to do this staff would do it for them. On the day of the inspection one resident was being escorted by staff to a dental appointment and another went on their own to the clinic for a blood test. When Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 16 one resident was asked where he got his glasses from he stated he had his own optician and was able to attend his own appointments. There was also evidence that where necessary other health care professionals were accessed for the residents, for example, dieticians. Residents were also supported to attend specialised groups such as alcohol counselling and anger management. Staff were aware of how family relationships and difficulties could affect the mental health of the residents and worked with the residents to try and improve relationships. Residents asked staff for their medication at the time they were due to take it to encourage responsibility for the management of medication whilst ensuring it was taken. Residents would then move onto the next stage of taking their own medication as part of a controlled programme. One resident was observed to monitor their own blood sugar level and was well aware of what it should be. Risk assessments were in place for anyone self administering any medication at all. Medication was administered via a 7 day monitored dosage system. The system was very well managed, all medication was acknowledged as being received into the home and the residents or staff signed the medication administration charts when it had been taken. There were protocols in place for staff to follow for the administration of PRN (as and when necessary) medication. One minor issue did arise and this was because some medication had not been returned to the pharmacist and it had not been included in the balance that was being held in the home. Consequently when audited the amount in the box did not correspond with what had been acknowledged as received and what had been administered. The manager also needed to undertake regular staff drug audits to ensure staff were competent when administering medication. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 17 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. Residents were confident that any issues they raised would be addressed. Residents were safe guarded by the policies and procedures in the home. EVIDENCE: There was an appropriate complaints procedure at the home and residents received a copy of this in the service user guide. Residents were satisfied that if they raised any issues with the staff they would be addressed. The relationships between the staff and the residents were very good and the atmosphere in the home was very relaxed giving the residents the confidence to raise any concerns. The home had not received any complaints since the last inspection and none had been lodged with the CSCI. Staff had received training in adult protection issues. There were policies and procedures on site in relation to the recognition and reporting of abuse. These had been amended since the last inspection and clarified the amount of information to be gathered before reporting a suspicion of abuse to the appropriate social worker. Charles Davies Hse (Hock) DS0000016862.V323503.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, 29 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 was well maintained and offered residents a good standard of accommodation. EVIDENCE: During the course of this inspection the communal areas of the home were seen as well as one vacant bed-sit and one vacant room. There had been no changes to the layout of the home since the last inspection. The home was safe and well maintained. Since the last inspection there had been some redecoration to some of the bedrooms, the hallway and one of the kitchens. New flooring had been fitted in the entrance hall of two units, the office and one bathroom. The bedroom and bed-sit seen by the inspector were adequately furnished and decorated. The bed-sit consisted of a combined sleeping and sitting room, Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 19 bathroom and kitchen. The kitchen was equipped with a washing machine and cooker. The inspector was informed that the four bed-sits were all the same and enabled the occupants to be very independent but to have assistance from staff if necessary and the company of other residents if they wished in the communal areas of the home. Each of the units where the single bedrooms were located had a lounge and kitchen. The kitchens were large and well equipped and residents had access to these at all times. One of the lounges was a smoking lounge the other was non smoking. Both included televisions, DVDs and music systems. The furnishings fittings and décor were of a good standard and all communal rooms were very homely. There were adequate numbers of toilets and bathrooms throughout the home to meet the needs of the residents. Residents did not need any specific aids and adaptations. One resident with a physical disability was housed on the ground floor and had access to all other areas without any difficulty. All the residents spoken with were happy with their rooms and the communal areas at the home. The home was clean and hygienic on the day of the inspection. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were supported by a stable staff team that could meet their needs. Recruitment procedures were robust and safe guarded residents. EVIDENCE: Only one staff member had left the home since the last inspection and this was the cook. The manager was due to interview to fill this post. Staff turnover at this home is very low which is very good for the continuity of support offered to the residents. Adequate numbers of staff were on duty to meet the needs of the residents. Relationships between the staff and residents were very good and all the residents spoken with were very happy with the staff team. Comments received from residents included: ‘I get on well with the staff.’ ‘Staff really care they are very understanding.’ ‘They do help if you want it.’ ‘Staff are o.k. They help if needed.’ Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 21 Recruitment records were not checked during this inspection, as no new staff had been recruited, but were found to be robust at the last inspection. All staff at the home had either NVQ level 2 or 3 which is to be commended. The training matrix for the home showed that not all regulatory training was up to date for staff, for example, basic food hygiene, manual handling and first aid. The manager was aware that staff needed their training updating on a regular basis to ensure they were able to work safely and was in the process of arranging updates. All staff had undertaken a range of training related to mental health issues including, self harm, voices and valuing the journey to recovery. Charles Davies Hse (Hock) DS0000016862.V323503.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 adequate. This judgement has been made using available evidence including a visit to this service. The home was well managed ensuring the health, safety and welfare of the residents were promoted and protected. A system for monitoring the quality of the service offered to the residents, with a view to continuous improvement, needed to be in place. EVIDENCE: The registered manager had worked at the home for a considerable amount of time. She had the required qualifications to fulfil her role, had a good knowledge of the needs of the residents in her care and the running of a residential home. It was evident throughout the course of the inspection that relationships between the manager, residents and staff were good. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 23 There was no formal quality monitoring system in place at the home. Several systems were in place in the home for the ongoing monitoring of the health and safety in the home and there were regular meetings with staff and residents. Residents were very much involved in the day to day processes in the home and their views were always taken into account. A formal system for quality monitoring needed to be in place that was regularly audited and resulted in a yearly development plan for the home. Health and safety at the home were well managed. There was evidence on site of the up to date servicing of all equipment and all the in house checks on the fire system had been carried out regularly. There had been a recent fire drill, which included the residents, and staff fire training had been updated since the last inspection. The most recent visit from the fire officer was very favourable and no requirements were made. The recording and reporting of accidents and incidents in the home were appropriate. Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 4 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 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Charles Davies Hse (Hock) DS0000016862.V323503.R01.S.doc Version 5.2 Page 25 Yes. 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 YA6 Regulation Requirement Timescale for action 01/02/07 15(2)(b)(c) Individual plans must be put in place indicating how the goals identified were going to be achieved, with timescales and identifying how the residents would be supported to achieve their goals. (Previous time scale of 01/04/06 not met.) 13(4)(c) All residents must have in place a risk assessment and management plan that includes details of how staff will know when the residents’ mental health is relapsing and how this is to be managed. The registered must ensure that all medication that has not been returned to the pharmacist is included on the MAR charts. Regular staff drug audits must be undertaken before and after a drug round to ensure the competency of staff. Any discrepancies found must be addressed. The registered manager must ensure that staff receive regular DS0000016862.V323503.R01.S.doc 2. YA9 01/02/07 3. YA20 13(2) 14/01/07 4. YA35 18(1)(a) 01/04/07 Charles Davies Hse (Hock) Version 5.2 Page 26 5. YA39 updates for all their mandatory training. 24(1)(a)(b) The home must have in place a 01/04/07 quality monitoring system based on seeking the views of the residents that results in a yearly development plan that details how the service is to be further developed. 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 Charles Davies Hse (Hock) DS0000016862.V323503.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 Charles Davies Hse (Hock) DS0000016862.V323503.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. 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