Inspection on 06/02/07 for Church Road (104)

This inspection was carried out on 6th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Road (104) 08/03/06

Church Road (104) 26/07/05

Church Road (104) 01/02/05

Church Road (104) 15/07/04

Church Road (104) 28/01/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Church Road (104) 104 Church Road Bebington Wirral CH63 3EE Lead Inspector Beate Roth Unannounced Inspection 6th February 2007 1.00 Church Road (104) DS0000018976.V321278.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 Church Road (104) DS0000018976.V321278.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. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Road (104) Address 104 Church Road Bebington Wirral CH63 3EE 0151 201 1923 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) jane.roberts@wirral.autistic.org Wirral Autistic Society Jane Anne Roberts Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager is to complete her NVQ Level 4 in Management. The Manager to be registered for 134A Allport Rd for 3 months until an application to relinquish the registration of the home has been processed. 8th March 2006 Date of last inspection Brief Description of the Service: 104 Church Road is registered to provide personal care for two adults with autism. The home is a two storey semi-detached property located in a residential area. On the ground floor there is a lounge, a kitchen and a dining room. On the first floor there are two single bedrooms, an office/staff sleep in room, and a bathroom. There is a patio and a garden to the rear of the home. Parking is available on the drive or on the main road. 104 Church Road is close to local shops and to public transport services. The home is run by Wirral Autistic Society who have several care homes for adults with autism in the area. Wirral Autistic Society provides a range of services and facilities, which are fully utilised by the service users, accommodated at 104 Church Road. At the time of the inspection, the weekly cost for the service ranged from £1130.00 to £1281.00. A copy of the statement of purpose, which describes the services offered at 104 Church Road, is made available to relatives and social workers. The service users guide to the home is made available before a service user comes to live at the home and the content is discussed with them, where possible, to ensure their understanding. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours and is based on a visit to the home, information received about the service since the last inspection and by questionnaires completed by the manager, service users and their relatives. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with service users and staff. What the service does well: What has improved since the last inspection? Since the last inspection there has been an improvement to record keeping. Risk assessments have been made available where service users stay at home with no staff support and there is a risk assessment available for service users who administer their own medication. A monthly visit by the registered provider or their representative is being carried out on a regular basis and a written report is available at the home and a copy made available to CSCI. Care planning information has been revised since the last inspection so that more detailed guidance is available for staff around the specific care needs of service users. Communication passports have been completed for service users since the last inspection. These provide clear information on the communication needs of service users and there was evidence that staff are working with this information to support service users. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Church Road (104) DS0000018976.V321278.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 Church Road (104) DS0000018976.V321278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The assessment process ensures that the service is only offered to individuals whose needs can be met at the home. Service users are able to make several visits to the home to make sure it is right for them before moving in. The contracts/terms and conditions support the interests of service users. EVIDENCE: No new service users have come to live at the home since the last inspection. At the last inspection a new service user had come to live at the home and the records showed that a thorough assessment had taken place before the service user moved in. The initial assessment indicates the communication, religious and cultural needs of a new service user. New service users are assessed by the manager for the home and by a representative from day services. The manager visits a prospective service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. If a service user moves to the home from another home run by Wirral Autistic Society, an assessment of the service users needs is undertaken. New service users can make a number of visits to the home to get to know the service, meet the staff and other service users. These visits are planned in Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 9 accordance with the needs of the new and existing service users. Parents/carers and representatives from placing authorities are also able to make visits to the service. The contracts/statement of terms and conditions between the home and the service users were seen. These documents contain the required information. A representative of one service user has signed one document. The other contract/statement of terms and conditions is not signed by the service user in accordance with the service users wishes. Work has taken place to identify an advocate so an individual independent of the home agrees the contract meets the service users best interests, however the manager reported that an advocate could not be identified. It is recommended that the social worker for the service user be approached with regards to this issue, in accordance with the service users wishes. In this case due consideration must be given to the provisions of the Mental Capacity Act 2005 in reaching decisions in the best interests of the service user. Church Road (104) DS0000018976.V321278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Care planning reflects the assessed and changing needs of service users. The independence of service users is well promoted, however, improvements are needed to the recording around some risk assessments in this area in order to show that service users are fully safeguard by the home’s practices. EVIDENCE: The service user plans were examined and contained clear information to enable staff to provide appropriate support around day-to-day living and personal goals. Since the last inspection, care planning information has been updated to provide more detailed information for staff on meeting service users needs. A review had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to reviews. A service user interviewed was aware of their care plan and they Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 11 commented positively on the support they receive from staff. A questionnaire returned by a relative indicated that they are more than satisfied with the care provided. The service user plans indicated that service user’s rights to live as independently as possible, in accordance with their abilities, is promoted by the home. Risk assessments are available in order to safeguard service users and promote their independence. A risk assessment was available with regards to a service users relationships outside the home. This did not cover all the circumstances that had informed the decision that it was in the best interests of a service user to visit the houses of friends independently or stay overnight. A risk assessment to indicate that it was in the best interests for a service user to go on holiday independently was not available. This information needs to be documented in order to demonstrate that risks to safety have been identified, assessed and appropriate action taken where necessary. Communication passports have been completed for service users since the last inspection. These provide clear information on the communication needs of service users and there was evidence that staff are working with this information to support service users. Service users are encouraged to contribute towards the running of the household. Service users go shopping and help with meal preparation in accordance with their abilities. Service users’ views are obtained through their individual key workers. Service users are able to make their views known about the day care services offered at a service user run advocacy group, which meets every week. The policies and procedures have been made available in formats that make them more accessible to service users where this is possible. Church Road (104) DS0000018976.V321278.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. 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 visiting the service. Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. Links with the local community are promoted. The daily routines and arrangements for promoting relationships with family and friends, support service users. Varied and well-balanced meals are provided in homely surroundings. EVIDENCE: Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 13 Service users attend day services where they are provided with a range of opportunities to promote their personal development. Service users have a timetable of activities, which has been drawn up to meet their needs, skills and individual preferences. Some of the opportunities available are horticulture, craftwork, community work experience, drama and physical education. Activities are provided by either Wirral Autistic Society’s day services or by outside organisations such as local colleges. Service users are provided with work experience opportunities in accordance with their abilities. Records and a discussion with staff and a service user indicate that there are opportunities for service users to become involved in the local community in accordance with their wishes. The home has access to private transport and there is easy access to bus services. Staff and records indicated that family links and friendships are promoted. The arrangements for contact with family are written into the service users’ care plans. A questionnaire returned by relatives indicated that the care home helps to ensure contact is maintained. A service user spoken with said that they have the opportunity to meet people and make friends with people who do not have their disability, through attendance at social clubs and through community activities. As already indicated care needs to be taken to ensure that a clear record is made of how service users safety is promoted alongside their rights to independence. Discussions with a service user, the staff and observations confirmed that the home’s routines are flexible as much as possible and fit in with the needs and wishes of the service users. Care plans indicate the dietary requirements of service users. Advice is obtained from a dietician if this is required. A record is kept of food provided to service users. The records showed that well-balanced and varied meals are provided which meet the cultural background of the service users. A service user spoken with said that they help choose the meals and do the shopping and cooking with staff support. Church Road (104) DS0000018976.V321278.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. 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 visiting the service. The health and personal care needs of service users are well met. Service users are in general protected by the home’s procedures and policies for the management of medication. EVIDENCE: Records clearly detail the support service users need with their personal care. The routines of service users are documented and are provide good guidance for staff on how to support the service users. Observations indicated that staff, promote the privacy and dignity of service users. Consistency and continuity of support for service users is provided through the key worker system. Staff receive training on promoting privacy and dignity during their induction. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 15 Records of reviews and a discussion with a service user indicated that service users have access to medical/health care professionals as needed. Service users are supported to attend health care appointments. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A service user spoken with said that the staff provide good support around helping to arrange health care appointments. A questionnaire returned by relatives indicated that all medical needs are dealt with promptly. A questionnaire returned by a GP indicates that the home communicates clearly and works in partnership, medication is appropriately managed and staff have a clear understanding of the needs of service users. A medication procedure is available which provides clear guidance. Medication is stored securely. The records of training indicated that staff have been trained in the safe handling and administration of medication. A selection of medication administration record sheets and corresponding medication were inspected and found to be in order. Since the last inspection, a risk assessment has been made available for a service user who administers their medication. The service user spoken with was very aware of the need to keep their medication secure. At the time of the inspection the service users bedroom was locked, however, medication was not stored in the lockable area provided. It is strongly recommended that the home encourage the service users who self medicate to store their medication in the lockable facility that is provided. Church Road (104) DS0000018976.V321278.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. 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 visiting the service. Staff training and policies and procedures are in place to ensure that service users views are heard and appropriate action taken. The practices at the home provide protection for service users form abuse. EVIDENCE: Information is available to enable a complaint to be made by a service user or on their behalf, by an advocate. The complaint procedure includes the timescales for dealing with each stage of a complaint. The complaint procedure is displayed on the service users’ notice boards. The procedure is available in different formats to reflect the abilities of service users. A record is kept of any complaints made. The records indicated that one complaint had been made since the last inspection and that appropriate action has been taken to investigate this. No complaints have been made to CSCI since the last inspection. A service user who spoke to the inspector said that if they wanted to complain or comment about any aspect of the service they receive at the home they would know who to approach. Staff are aware of how to respond to a complaint. Staff reported that they continually find out the views of service users in accordance with their abilities and attempt to resolve any issues that arise. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 17 A copy of Wirral Borough Council’s adult protection procedure was available at the home. All staff who work at the home have received training in the adult protection procedures. A member of staff spoken with had a good understanding of the adult protection procedures. Since the last inspection, work has taken place with service users around what abuse is, how to report abuse and steps they can take to keep themselves safe. From discussion with a member of staff and from an examination of the financial records, the home’s policies and practices with regards to service users’ money and financial affairs in general safeguard service users. Monies held at the home, on behalf of service users are checked daily by staff, audited by the manager on a monthly basis and by the representative of the registered provider at their monthly visits. Receipts are maintained and records are signed by staff. A record was not made around the decision to access a service users money on occasion without the service user being first informed in order to ensure the service user benefits from activities and holidays. The service user is independent in many areas and the reasoning behind this decision was not clearly documented and there was no evidence that the service users social worker, and relative/advocate (if appropriate) had been consulted. Following the inspection, the manager reported that this information has been recorded, the social worker consulted and that the work that takes place on an on-going basis, with the service user around the anxiety of spending money, will be documented. Church Road (104) DS0000018976.V321278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The home provides a safe, clean and pleasant environment for service users. EVIDENCE: The premises provide a comfortable environment for service users, are in general well maintained and there is evidence of ongoing improvements to maintain standards. The kitchen units are in working order but showing some signs of wear and tear and some units would benefit from replacement, the paint to the windowsill in the dining room is chipped, there is an iron burn to the carpet in the dining room. The manager reported that these works are in the process of being attended to. Service users bedrooms are personalised and promote their lifestyle choices. Where appropriate service users have access to a key to their bedrooms to ensure their privacy. Steps have been taken to ensure the safety of service users at the home. Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 19 Window restrictors and temperature-controlled water are provided. A risk assessment of the security arrangements provided by the doors at the home has taken place and steps taken to increase the homes security. Risk assessments of radiators that are unguarded and not temperature-controlled indicate that they do not pose a risk to service users. It continues to be recommended that design solutions that control the risk from radiators that can exceed 43 degrees centigrade be provided. The home was clean and odour free at the time of the inspection. Church Road (104) DS0000018976.V321278.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. 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 visiting the service. Service users are supported by competent staff who have access to good training opportunities. Staff are appropriately deployed to meet the needs of the current service users. The practices around engaging individuals not employed by Wirral Autistic Society to offer therapeutic services and the practice of staff taking service users to their own homes do not fully safeguard service users. EVIDENCE: An examination of the rota indicates that the home is providing sufficient staffing levels. There is one member of staff on duty at all times. There is a network of support provided by Wirral Autistic Society for lone workers. Lone worker risk assessments are available. There are currently three permanent staff working at the home with absences being covered by permanent or bank staff. Bank staff have been recruited to work for Wirral Autistic Society to cover absences in the homes if needed or to provide support within the day care service. A comprehensive induction and foundation training programme is provided to permanent staff. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 21 targets. This training is also provided to bank staff so as to ensure that they are appropriately trained should they need to be deployed. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. Staff are encouraged to undertake an NVQ in caring for adults with a learning disability. At present 1 out of 3 staff hold a relevant NVQ. Further staff are undertaking this training in order to ensure that at least 50 of staff hold this qualification. Specialist training is provided to staff to assist them to support service users as appropriate. Training is provided to staff around equal opportunities. The records of recruitment for one new member of staff were seen. The recruitment records contained all the required information and were well maintained. However it was apparent that a criminal records bureau check had not been undertaken for a volunteer who provides Reiki to the service users on an unpaid basis. The manager reported that this activity is supervised but there was no documentation to support this. The registered manager must remain mindful that in circumstances were someone visits the home to provide a form of therapeutic service, whether this is on a paid basis or not, then they should be subject to a criminal records bureau check in order to sufficiently safeguard the service users. The level of the check required will be dependent upon the nature of the service provided and the frequency of the involvement. At present there is no system in place for routinely updating CRB checks. The manager reported that this is in the process of being addressed. Service users visit the homes of the permanent staff who work at 104 Church Road. The manager reported that these visits are not frequent, that service users enjoy these visits, look forward to them and are a basis for positive relationships to be developed with staff. However there are a number of issues that had not been adequately considered and specifically the procedure and risk assessments for this practice were not robust enough to sufficiently safeguard service users. The effect of this practice on staff maintaining a professional relationship with service users was not sufficiently addressed. The purpose of these visits and limitations were not clearly indicated. The manager confirmed that there is appropriate insurance to cover staff taking service users to their homes and that this practice is monitored to ensure that it is not meeting the needs of the staff rather than the service users however it was not clear as to how this is monitored. This information was not indicated in Wirral Autistic Society’s procedure for staff taking service users to their own homes. Church Road (104) DS0000018976.V321278.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The welfare of service users is supported by a well run home and by the quality assurance systems in operation. EVIDENCE: Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 23 The manager of the home has had several years experience of management in a care setting. The manager has a Diploma in Social Work and has completed an NVQ Level 4 in management. The manager has undertaken periodic training to maintain and update her knowledge skills and competence. The manager is responsible for three other small homes that are owned by Wirral Autistic Society. A member of staff interviewed reported that they consider their views regarding the running of the home are sought and listened to. A clear complaint procedure is available. Staff meetings are held every month. There are a range of quality assurance systems in place. Wirral Autistic Society is accredited by the National Autistic Society which carries out an inspection of services provided. Wirral Autistic Society conducts an internal audit of the society as a whole on an annual basis. The views of service users are obtained by key workers and the manager. Residents meetings are held each month. Questionnaires are sent to service users and their relatives regarding how the home operates. Visits to the home by the representative of the registered provider are made. These reports are made available to CSCI. The manager carries out a monthly house check of all reccords and the premises. The day service also provides a forum for service users to give their views on the services provided there. The manager reported that questionnaires for health and social care professionals are in the process of being devised. The records relating to the checks of the gas safety and electrical wiring were seen and were in order. The records of fire equipment checks indicated that the fire alarm and emergency lighting are tested at appropriate intervals and that fire drills take place on a regular basis. Church Road (104) DS0000018976.V321278.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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Church Road (104) DS0000018976.V321278.R02.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13 Requirement The registered persons must ensure that risk assessments identify any risks to a service users safety, demonstrate an appropriate assessment has been completed and safeguards put in place to minimise any risks identified. Timescale for action 06/02/07 2. YA23 13 The registered persons must 06/02/07 ensure that where a decision is made to act on behalf of a service user who demonstrates capacity to understand the action taken, the decision making behind this needs to be clearly documented and evidence that the service users social worker, and relative/advocate (if appropriate) has been consulted needs to be documented. The registered persons must ensure that a criminal records bureau check is undertaken for any individuals who have regular contact with service users. The registered persons must ensure that the procedure and DS0000018976.V321278.R02.S.doc 3. YA34 19 06/02/07 4. YA34 13 06/03/07 Church Road (104) Version 5.2 Page 26 risk assessments for the practice of staff taking service users to their own homes is sufficiently robust to safeguard service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations It is recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the service users in accordance with the wishes and abilities of the service users. It is strongly recommended that the home encourage the service users who self medicate to store their medication in the lockable facility that is provided. It is recommended that design solutions that control the risk from radiators that can exceed 43 degrees centigrade be provided. It is recommended that an evidence based recording system be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. 50 of care staff are to hold an NVQ qualification or equivalent. It is recommended that a system be introduced for renewing criminal records bureau checks. 2. 3. YA20 YA24 4. YA35 5. 6. 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