Inspection on 13/09/06 for 64 Chesterwood Road

This inspection was carried out on 13th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

64 Chesterwood Road 25/01/06

64 Chesterwood Road 26/09/05

64 Chesterwood Road 05/01/05

64 Chesterwood Road 21/09/04

64 Chesterwood Road 23/03/04

64 Chesterwood Road 23/09/03

64 Chesterwood Road 20/08/02

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Chesterwood Road, 64 Kings Heath Birmingham West Midlands B13 0QE Lead Inspector Kerry Coulter Key Unannounced Inspection 13th September 2006 10:00 Chesterwood Road, 64 DS0000016716.V310011.R02.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 Chesterwood Road, 64 DS0000016716.V310011.R02.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. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chesterwood Road, 64 Address Kings Heath Birmingham West Midlands B13 0QE 0121 444 3736 0121 444 3736 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) suehullin@tracscare.co.uk TRACS Mrs Sheila Lynn Horton Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Residents must be aged under 65 years The home may provide care for 6 service users with an acquired brain injury. That the Registered Manager is employed to work no less than 28 hours each week. That the effectiveness of the management structure in the home be reviewed by TRACS and the CSCI every three months. That a full time deputy manager be employed to work in the home. Date of last inspection 25th January 2006 Brief Description of the Service: 64 Chesterwood Road is owned by TRACS and provides a service for up to six adults. The home is registered to accommodate people with a learning disability and physical disabilities. The home currently accommodates four service users who have an acquired brain injury. 64 Chesterwood Road is a two-storey traditional style detached residence situated in the middle of a quiet residential road in Kings Heath, Birmingham. The home is within walking distance of a variety of community facilities, which includes shops, parks, a leisure centre, places of worship, pubs, restaurants and a good selection of public transport. There is off road parking to the front of the property and a well-maintained garden to the rear. A wooden ‘chalet’ has been erected at the bottom of the garden to provide an area for staff meetings and breaks. Service Users and staff assist in maintaining the garden areas. There are two ground floor bedrooms one with en-suite shower facilities, ground floor shower room and toilet and four single bedrooms on the first floor. There is a communal lounge / dining area, kitchen and laundry facilities. A new conservatory has recently been completed. The laundry area is housed in a ‘lean-to’ undercover area, adjacent to the office. The current scale of charges for the home is £1032.71 to £1904.23(Variable £2584.92 when required). Visitors to the home can request to see a copy of CSCI reports from staff as these are located in the home’s office. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, reports from the provider and a pre inspection questionnaire. The unannounced fieldwork visit was carried out over eight and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. All service users who live at the home were spoken with. Some service users completed a CSCI comment card, but not all wanted to do so. Time was also spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. The Manager and staff were spoken to. What the service does well: The people who live at 64 Chesterwood Road generally report that it is a good place to live, that they like the staff that support them, and that they are satisfied with the opportunities available to them. The staff are friendly and helpful. There are some staff who have worked in the home for a long time. The staff team is stable, and people are supported by staff they know, and who are familiar with their needs. The food available is very varied. The staff buy good quality brands of food. There is a planned menu, but there is a lot of flexibility about what is eaten, and it was good to see people making and eating food that they fancied. All the people living at Chesterwood have a single bedroom. These are all very different, and each persons room contains the things that are important to them. The people who live at Chesterwood, staff and visitors are well protected by regular servicing and inspection of health and safety appliances. The staff help people to stay in touch with family and friends. This is in person, by phone and by letter. The commitment of staff to helping people with this is commendable. There is a very open culture and comments and ideas are welcomed from people living in the home, staff and others. It was good that service users rights to see records held about them was respected. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 6 The home has a strong manager. She has undertaken the required training, and is registered with the CSCI. She and the staff team work hard to make sure the service is focussed on the people who live in the home. 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. Chesterwood Road, 64 DS0000016716.V310011.R02.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 Chesterwood Road, 64 DS0000016716.V310011.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. TRACS offers potential service users and other people important to them a chance to visit the home prior to moving in. An assessment is undertaken prior to moving in to ensure the home can meet their needs. EVIDENCE: The home has produced a Statement of Purpose and Service Users guide. These were both informative, and written in an accessible format. The documents help the reader form an impression of the type of support and service offered at Chesterwood. Discussion with the Manager indicates that these documents are available in an audio cassette version if needed. Information in the guide was seen to be current, however the document was undated. It would be good practice to date the document to make it easier for the Manager to assess when it is due for review. The home has had two recent vacancies but no new service users have moved into the home. The Manager said that it was not a good time to admit service users as building alterations were ongoing with a vacant downstairs bedroom. A potential new service user had been referred to the home. Sampling of the assessment document and discussion with the Manager shows that full assessment has been completed. Part of the assessment covered issues of compatibility with the current service users. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 9 The Manager had clearly recorded as part of the assessment some of the individual needs that the home would be unable to meet. The Manager clearly demonstrated a good knowledge of the assessment process. Comment cards returned by service users show they were consulted about moving to the home. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of case tracking the plans of two service users were assessed. Both plans had been reviewed recently. These detailed how staff are to support the individual to meet their communication, health, dietary, personal care and social needs, cultural needs, maintain contact with their family and friends, develop their independence skills and achieve the goals that are set. The care plans were centred on the individual, their likes and dislikes and the things they would like to do. Review meetings are held and service users have the opportunity to attend the meeting. It is good that prior to the meeting the key worker completes a preparation booklet with the service user. This gives the individual the opportunity to plan what they want from their meeting before it takes place. A number of goals had been set by the service user at the last review. When tracked these had been translated onto the activity planner, and the daily notes showed these had been undertaken as planned. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 11 Service user meetings are held on a regular basis, issues discussed include choice of activities, the environment and menu’s. Minutes included the dates for things to be achieved and outcomes so that progress is tracked. Risk assessments for the two case tracked individuals were sampled. These detailed how staff are to support the individual to minimise risks for activities such as travelling in the home’s vehicle, smoking, accessing the community and with their behaviour. Assessments sampled were satisfactory and had been regularly reviewed. The information pertaining to service users was well stored and managed. No breaches of confidential information were noted during the inspection. Training on confidentiality forms part of the induction for staff new to the home. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to undertake activities of their choice on a regular basis. The staff undertake a lot of work with service users to ensure relationships are maintained with family and friends. Food offered and served is varied, nutriticious, and to the service users liking. EVIDENCE: Each service user has their own activity schedule, this is completed weekly with the individual and links into goals and agreed actions included in the care plan. The range of opportunities are very positive and include exercise, skill development and leisure. Activities include attendance at ‘drop in’ clubs, guitar club, photograph recognition sessions, fire safety and food hygiene courses, shopping and visits to pubs and restaurants. One service user spoke about how he was soon going away with staff to Blackpool for a few days. He said he went there last year and enjoyed it and so wanted to go there again. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 13 One service user was not entirely satisfied with the activities on offer but discussion with staff and sampling of records indicates that attempts are being made to find activities that the service user will enjoy. Other service users spoken with were happy with the activities on offer. The staff show a strong commitment to helping service users stay in touch with people who are important to them. This includes making visits in person, having people visit them at Chesterwood Road by letter and by phone. One service user said that he was going out with staff that day to buy a card for his Mother. It is good that service users are assisted to widen their circle of friends, one individual is supported by staff to write to a pen pal as part of the ‘Link Up’ scheme. A record is maintained of all contact so that staff can track how often service users have contact with friends and family. Service users rights are respected, as stated earlier in this report staff were observed to offer choice through out the visit. Where restrictions had been placed on individuals, such as locking of the front door for their own safety the rationale for this was recorded in the care plan and risk assessed. It was good that service users rights to see records held about them was respected. One individual has accessed their own daily records and a record had been kept where the individual had disagreed with what had been written by staff. Service users are encouraged to be as self managing as possible, this includes getting involved in things such as making their own meals and drinks. Food records sampled and discussion with service users showed that choice is offered to service users. The home does have a planned menu. It was very positive that this is developed and changed by service users, if they fancy a meal different to that planned. Service users were observed to have free access to the kitchen, and to help themselves to food and drinks. The lunchtime meal was observed. The lunch served was freshly prepared and well presented. It was positive to see that service users and staff sat together to eat and a nice atmosphere was created. Discussion with service users shows that they have the opportunity to go with staff to shop for food. Staff spoken with said that a variety of shops are used depending on the preference of service users. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal and healthcare support in the way they prefer and require and their health needs are generally well met. Medication management was generally good, ensuring service users get the right medication at the right time. EVIDENCE: The morning routine was relaxed. Service users were dressed in good quality clothes appropriate to their age, gender and the weather. Care plans sampled had detailed morning and evening routines, detailing how they like their care needs to be met, and the areas in which they require support. The healthcare appointments for two service users were tracked. It was evident these had been undertaken as required. Records sampled showed that they had regular check ups with the chiropodist, dentist, GP and the optician. The records regarding health appointments were generally well maintained to include details of what the appointment was for and the outcome. This is further detailed in Standard 41. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 15 Medication management was good. Staff have received medication training. Medication is stored in a locked cabinet. Copies of prescriptions are retained so that staff can check the correct medication has been received from the chemist. Medication Administration Records (MAR) had been signed appropriately. Where service users are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. One medication error has been made since the last inspection, the CSCI were notified about this. Discussion with the Manager and the member of staff concerned shows that appropriate action was taken to reduce the risk of future errors. As a precaution the member of staff said they had completed the medication training booklet again. The unexpected death of one service user was reported to the CSCI as required. Discussion with service users and staff shows that appropriate support was given during this difficult time. One member of staff commented that counselling and a debriefing session had been offered. Chesterwood Road, 64 DS0000016716.V310011.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users views are listened to and acted on. Arrangements are generally sufficient to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The CSCI has received several complaints about this home since its last inspection, these all came from the same complainant. Issues complained about included staff overspending on food, where food shopping was done, medication, the type of toilet seats fitted, having to cook meals and how staff responded when a service user was unwell due to diabetes. These complaints were passed to the Provider to investigate. All but the issue regarding diabetes were not upheld. The homes complaint log recorded complaints received and detailed the action taken in response. A complaints procedure is available along with a complaints leaflet. This information is also available in an audio tape format for service users who are unable to read. Two service user files sampled had a record of the complaints procedure being explained to the individual. Adult protection training is undertaken by staff as part of their induction and then refresher training. It has recently been raised at other inspections of TRACS homes in Birmingham that the duration of this training is quite short. The Manager said that additional external training has now been booked for staff at Chesterwood. The success of this training will then be evaluated to see if it would be beneficial to staff at other TRACS homes. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 17 Discussion with staff and observation of records shows that staff receive training in physical intervention, staff were aware that it should only be used as a last resort to protect service users. An allegation of an adult protection nature has been made since the last inspection. This was reported appropriately to the CSCI and adult protection procedures were followed. Inventories of service users possessions are kept and regularly updated. This shows that staff at the home assist individuals in looking after their possessions and have a system to monitor if anything goes missing. Chesterwood Road, 64 DS0000016716.V310011.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. TRACS is working hard to improve the accommodation at Chesterwood to ensure that service users are provided with a comfortable and homely environment. EVIDENCE: The Provider continues to take positive action to improve the premises. A ramp has been built to provide better access for individuals with mobility difficulties to access the garden. Service user bedrooms have also been repainted, service users spoken with confirmed that they had chosen the colours. Work is also underway to enlarge a ground floor bedroom in readiness for an existing service user to move to this room from a smaller bedroom. It was required at the last inspection that free standing wardrobes in service users bedrooms be secured to the wall at the last inspection. It was evident from new brackets fitted to the wardrobes that this had been done, unfortunately following repainting of bedrooms not all of the wardrobes had been re-secured to the wall. This was addressed by the Maintenance Worker during the visit after it was brought to the attention of the Manager. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 19 The kitchen requires replacement, and the Environmental Health Officer recommended this in November 2005. Discussion with the Manager and Maintenance Worker indicates that work to do this was scheduled to commence two weeks after this inspection visit. A requirement was made at the last inspection to re-carpet the ground floor hallway as the carpet was worn. The Manager said this had not yet been done as it had since been identified that the joists below the floor needed repair. These joists have now been repaired. Currently building works are being undertaken adjacent to the hallway and due to this it would not be a sensible time to replace the hall carpet. An extension to the timescale for this requirement has therefore been given. There is a long-standing issue with access to the laundry. TRACS have undertaken all possible action to address this within the restrictions of the current premises. Recent planning permission has been granted to convert the loft area, it is planned this will be used for a new office as access for the laundry currently entails walking through the ground floor office. The home was clean with no unpleasant odours. One service user said that they did not like the fact that the shower was sometimes dirty, they said they would much prefer to have the facilities of having their own shower. It was not possible to evidence that the shower is sometimes dirty as it was clean at the time of the visit and the issue was not raised by anyone else. The Manager has also stated that the shower area is always cleaned within ten minutes of being used. Chesterwood Road, 64 DS0000016716.V310011.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing and their support and development are generally sufficient to ensure that an effective staff team supports service users and meets their individual needs. Service users are protected by the home’s recruitment policy and practices. EVIDENCE: Staff spoken with had a good understanding of the needs of the individuals in their care. It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. Support to service users is given in a warm and friendly manner, and staff were seen to be polite, considerate and patient. 67 of staff have completed an NVQ in care, this meets the standard of having 50 staff trained. It was good that the Manager had already arranged for a new member of staff to start an NVQ in care. This staff member said he had felt very supported at the home as he had been given lots of help and guidance by the other staff. Rotas show that there are usually four staff on duty during the day and two at night. Staff spoken with felt that staffing levels were appropriate to the needs of the service users. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 21 The recruitment files of two staff were sampled. These contained all the required information to show that a robust recruitment process had been followed. Records also evidenced that service users had participated in the recruitment process. Staff were undertaking health and safety and fire training on the day of the inspection visit. As stated earlier in this report external adult protection training has been arranged in October. One staff commented that the training was excellent and they got everything they needed. Sampling of the training records for a newer member of staff showed that they had done an induction to the home and in the few months they had been at the home had completed physical intervention, mental health and food hygiene training. Initially it was difficult to evidence that some staff had completed their physical intervention refresher training as it was not recorded on their training records, however staff were able to confirm the date of attendance. A matrix was available for staff supervision but this was not up to date. Supervision records and discussion with the Manager shows that staff do get at least six supervision sessions a year but that the frequency is variable. Sometimes staff go two months without formal supervision but then have supervision for the next two months to catch up. Supervision must be undertaken at least bi-monthly with all staff. Staff meetings are held regularly, one was taking place on the morning of the inspection visit. A strategy meeting had also been held with staff in July where staff had the opportunity to discuss things that would improve the home. Chesterwood Road, 64 DS0000016716.V310011.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service user’s views underpin development by the home. Health and safety is generally well maintained. EVIDENCE: The manager at Chesterwood is very service user focussed, and endeavours to provide a well run home. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are carried out periodically to include health and safety, financial and an audit called ‘first impressions’. Discussion with the Manager indicates that an external company had visited the home the previous day to conduct an audit of policies and procedures. It is good that a service user focus day was held in July, this was held with service users from other TRACS homes. Service users were consulted about what’s good, what’s not so good and how could things be made better. Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 23 Unfortunately the outcome of the consultation was not passed on to the Manager in a format that was specific to Chesterwood. It would be better if the Manager had access to information about this particular home so that service users views can be better taken into account when trying to improve things. Service user daily records were sampled and were generally satisfactory completed. Staff were not judgemental in their entries and records were dated and signed. Daily records are recorded on loose leaf numbered pages, some of these had become mixed up in their order. It is recommended that to ensure records are not lost or mixed up a system of attaching the completed records is introduced. Some improvement is needed to record keeping, for example the staff supervision matrix was not up to date, some staff training records were not up to date. Health records were generally well maintained although one entry regarding a blood test did not record what the test was for. The health and safety records showed that all routine tests and servicing of gas, electric and fire equipment had been undertaken. As required at the last inspection a heat detector has been fitted in the conservatory. It is good that service users have the opportunity to attend fire training, this helps ensure they will respond appropriately in the event of a fire occurring. Chesterwood Road, 64 DS0000016716.V310011.R02.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X 2 3 X Chesterwood Road, 64 DS0000016716.V310011.R02.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 YA24 Regulation 23(2)(a) Requirement Re-carpeting of the ground floor hallway of the home must be undertaken. Previous requirement, timescale extended. A review of the current laundry facilities is required. Access to the laundry is not satisfactory, through the staff office / sleeping in room. Alternative access to the laundry must be explored. Previous requirement. Building plans have been explored. Progress towards meeting the requirement made. Supervision must be undertaken at least bi-monthly with all staff. Outstanding requirement from 01/04/06. Ensure records are maintained to a good standard and are kept up to date. Timescale for action 30/01/07 2. YA24 YA30 16(2)(f)(j) 30/03/07 3. YA36 18(2) 30/11/06 4. YA41 12(1) 17(2) 30/11/06 Chesterwood Road, 64 DS0000016716.V310011.R02.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. 2. 3. Refer to Standard YA2 YA14 YA42 Good Practice Recommendations The Service User Guide and Statement of Purpose should be dated to show they are current documents. It is recommended that additional drivers be recruited/provided at weekends. Previous requirement, not assessed at this visit. Daily records are recorded on loose leaf numbered pages, some of these had become mixed up in their order. It is recommended that to ensure records are not lost or mixed up a system of attaching the completed records is introduced. Information from the service user consultation day should be made available in ‘home specific’ format to the Manager. 4. YA39 Chesterwood Road, 64 DS0000016716.V310011.R02.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: 0845 015 0120 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 Chesterwood Road, 64 DS0000016716.V310011.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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