Inspection on 22/02/07 for Connect Community

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Connect Community 28/02/08

Connect Community 22/03/06

Connect Community 14/10/05

Connect Community 21/03/05

Connect Community 27/11/04

Connect Community 24/02/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Connect Community 19-21 Park Road Moseley Birmingham West Midlands B13 8AB Lead Inspector Sean Devine Key Unannounced Inspection 22nd February 2007 09:00 Connect Community DS0000016863.V326514.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 Connect Community DS0000016863.V326514.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. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Connect Community Address 19-21 Park Road Moseley Birmingham West Midlands B13 8AB 0121 449 2204 0121 449 6124 admin@connecttc.org 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) Connect Therapeutic Community Limited Ms Carol Ann Gordon Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can provide care and accommodation for up to 10 service users of either gender between the ages of 18-65 years of age suffering with a mental health problem (MD). 22nd March 2006 Date of last inspection Brief Description of the Service: The home is situated south of the city centre and lies close to a frequent bus service into Birmingham. The property is part of a large Victorian terrace, and is similar in appearance to others on the road. The building has been adapted throughout its history and has several corridors, stairways and changes of level inside. There are two front doors, only one of which is in general use, and this is accessed via a walled and gated front. There is a garden to the rear of the property, which contains a greenhouse, some lawned and flower areas and a laundry. Office spaces, lounges, therapy rooms, a kitchen and dining room are found on the ground floor. There is a mixture of double and single rooms on the first and second floor. Toilet and bathing facilities are communal. Connect provides care and support for up to ten people with mental health issues. The mission statement for Connect states. We are a therapeutic community providing high quality residential and non-residential psychotherapy for clients and support services to professionals working with them. Using Transactional Analysis as our main framework, we provide therapy for psychological, emotional or behavioural problems in order to promote life long, sustainable improvement to that individuals quality of life. The home provided pre-inspection information including guidance on current fees, which range between £1600.00 and £2200.00 each week. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken unannounced by one regulation inspector over a period of one day, the inspector had opportunity to meet most of the residents and many of the staff. Records about care were seen including health, social care and activities. A tour of the communal areas was undertaken. At the time of the visit there were four residents who were classed as “residential” and two who use “day services” but who live in the community. A residential resident and a prospective resident on a visit were case tracked. The home has not received any formal complaints about its service in the past 12 months and the Commission has not received any complaints. Prior to the inspection two of the homes residents returned a survey known as “have your say about…” and the assistant home manager completed a pre inspection questionnaire. What the service does well: The process of admission to the care home is very comprehensive and focussed upon the prospective resident wanting to recover; it involves healthcare professionals, visits to the home and psychological tests. Residents provided the following comments “I received information in a pack through the post, a lot of information I didn’t understand, however coming on visits helped me to understand the Community more” and “I visited the Community twice before I came, once for an afternoon and once for a threenight stay. I felt that I was given a lot of information and opportunities to ask questions before I moved in”. Residents undertake many various leisure activities such as going to the gym and yoga, and attend a weekly art group within the home. Some residents do attend college for education courses. The residents were very positive about the structure of therapy and felt that this had helped them, some comments from residents about the structure included, “that when there are things I want to do that don’t fit in with the timetable I feel supported in negotiating this” and “ I do make most decisions in the afternoon and evening mainly, as in the morning we have therapy group and structured mealtimes, throughout the day where we all sit and eat together”. Residents are supported to take control of their own lives and are able to manage their own finances, medication and develop their care plans with a focus on setting some targets. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 6 Residents who returned their surveys stated they know how to make complaints, and who to address the complaints. During the inspection two residents indicated that they had no complaints and there were no recent records of complaints available in the homes log. Staffing levels and the mix of staff skills is good to appropriately support residents, some comments from residents included, “mainly I feel listened to, however I don’t always feel it is acted upon as sometimes staff disagree with me and it feels at times that’s the end of the conversation” and “I always feel safe and well treated even if I am frustrated or upset about something”. 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. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 7 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. Connect Community DS0000016863.V326514.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 Connect Community DS0000016863.V326514.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): Standards 1, 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has fully demonstrated that they have the ability and processes to ensure that residents are provided with information and opportunity to decide on whether the home can meet their needs and expectations. EVIDENCE: Residents confirmed that they have access to and have received a service users guide, that when they have had questions about the service that these have been clearly answered during the three-day trial visit to the home. The residents believe they have been able to make a decision on whether the home is suitable for them. The home gathers a lot of information during the assessment process, including information from other agencies such as Social Care and Health and Mental Health teams, their own assessments including the trial visits and only when all information is available is the assessment passed onto a Steering Group who will make a decision on whether a placement can be offered. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 10 A resident was seen to have a detailed contract about terms and conditions of residency and also a form had been signed by the resident confirming their awareness of the Complaints policy and procedure. Some comments received at the Commission from residents about how the home supported them to choose whether the service was appropriate included; “I received information in a pack through the post, a lot of information I didn’t understand, however coming on visits helped me to understand the Community more” and “I visited the Community twice before I came, once for an afternoon and once for a three-night stay. I felt that I was given a lot of information and opportunities to ask questions before I moved in”. Connect Community DS0000016863.V326514.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): Standards 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. The home has not demonstrated it has the ability to ensure that all residents have an up to date care plan and that there are risk management plans with strategies to reduce risks; it is a concern that residents do not have a mental health relapse management plan. It was evident that residents are always consulted about how their care is delivered. EVIDENCE: A resident had a detailed Care Programming Approach including a comprehensive care plan and reviews completed by the supporting Mental Health Team, the latest review indicated it was coming towards the time to move on from Connect Community to more independent living. To enable this the home had written a therapeutic care plan covering the period of October 2005 through to March 2006, there was no current care plan. The resident had written her own plan for the next two years, including wanting to move into a flat, improved focus upon education and acquiring a part-time job, to Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 12 attend Connect Community as a day member, during the next year to work a way out of structure and for six months to attend mentor groups. On speaking to the resident and staff it was apparent that many of the goals had been met and the resident was looking forward to a more independent lifestyle and was confident that there was good support if and when it was needed. At present some personal risks have been identified for this resident and there were no risk management plans available to indicate what support the resident receives to help reduce associated risks. Three residents informed the inspector that each day the home has a group meeting and that you are expected to attend all the groups and accept it as part of the programme. The residents who returned the survey commented that there are well-defined structures, being a timetable for each day, and the residents agreed to keep to this. The resident also advised “that when there are things I want to do that don’t fit in with the timetable I feel supported in negotiating this”. Another resident commented on the survey that “ I do make most decisions in the afternoon and evening mainly, as in the morning we have therapy group and structured mealtimes, throughout the day where we all sit and eat together”. Connect Community DS0000016863.V326514.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has demonstrated it has the ability to meet the varied and diverse lifestyle needs of all residents, focussing on a structured day that will help them with their programme of recovery. The rules do require review as some are over restrictive and if such an issue is apparent for residents it must be managed through the individual risk management process. EVIDENCE: The residents who met with the inspector in part described how they spend their days, this included accessing many local amenities such as shops, the gym and local centres, spending sometime where appropriate with friends and families, attending college classes and taking the homes dog for a walk. The assistant community manager advised of other activities available and undertaken by residents, this included for example running and physical Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 14 exercise, bike rides, trips to local parks and art centres, yoga at the local centre, support to be a volunteer and learning different ways of cooking. There is also a weekly art group conducted in the art room at the home. Residents and staff are subject to certain rules and restrictions; the list is extensive and has been implemented as was deemed fit at the time it was needed. There was a degree of discussion about some of these rules with members of the staff team as some rules were in the opinion of the inspector inappropriate, examples of these were, food – the limits of how many snacks and fruit are allowed per day are as follows 4 biscuits, 1pkt of crisps and 2 pieces of fruit, no one is allowed to have more than this except with the permission of staff; Hygiene – take a bath or shower every day, and wash hair regularly at least every third day; Therapy groups – the news should be listened to at 8.55am during peer group meetings. Residents and staff advised that the Monday meeting has a main focus of planning the week’s food menu, shopping for food and cooking. Copies of the menu were seen and it appears to reflect the individual choices and preferences of residents. Mealtimes are very structured and all residents and most staff are expected to attend the meal, which is cooked by the residents overseen by the staff on a rotating basis. The residents who returned their surveys were positive about the structured mealtimes and considered it to be an important time of the day. The inspector met with one resident who was preparing a snack and tidying the kitchen and informed the inspector it is the responsibility of both residents and staff to keep the kitchen clean and tidy. Connect Community DS0000016863.V326514.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): Standards 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 home has demonstrated that it does have the ability to enable the residents to have their personal and healthcare needs effectively met, promoting privacy and individuality. Medication practices are generally good ensuring residents receive their prescribed treatment thus promoting their health and well-being. EVIDENCE: At present there are no residents who require assistance with their personal care. Residents seen by the inspector appeared to dress and present themselves in very individual ways, clearly making personal choices about their appearance. The residents who returned their surveys indicated that staff always treat them well and although they have structured days and spend a lot if time in groups their privacy is always respected and this was confirmed by another resident during the inspection. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 16 Health records were available that included access to planned healthcare services and there are frequent reviews, monthly with staff at the home and clinical reviews, which are six monthly and include case manager (from the care home), funding agency normally from Social Care and Health, psychology and the resident. All residents do take medication, some are self-administering and for some residents staff manage the medication. Self-medicating residents do have risk assessments, with a focus on self-harm, they are provided with locked facilities to store medicine in their rooms. These risk assessments do not assess whether the resident understands the reason for the medicine, storage, times to administer and possible side effects. There are no compliance checks to ensure medicine is safely stored and appropriately taken. The records for a resident whose medicines are managed totally by the staff were well maintained, including when medicine is received into the home, administered to the resident and when returned to pharmacy for destroying. Staff training records was sampled and included recent training in the safe handling of medicines. Connect Community DS0000016863.V326514.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure staff and residents are aware of how to make complaints and processes are clear; staff have received recent training about protecting adults from abuse and have confirmed they have a good procedure which will safeguard residents and be informative for referrals under local authority procedures. EVIDENCE: Residents who returned their surveys stated they know how to make complaints, and who to address the complaints. During the inspection two residents indicated that they had no complaints and there were no recent records of complaints available in the homes log. The residents have a regular community meeting, which is chaired and minutes taken by the residents; records show that there are often some gripes recorded such as not enough fruit and the dishwasher not washing properly, yet there are no records of how the staff have made improvements where these are required. The assistant community manager has started to record gripes about maintenance issues within a book. He advised that at future community meetings residents would be updated on any concerns they had shared at previous meetings. The residents manage their own money, however the home does provide a safekeeping service for valuables such as passports, bank cards; a record is Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 18 kept of such valuables when they are either put in or have been taken out of the safe. Staff training records was sampled and they did include recent training on adult abuse awareness and protection. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 19 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): Standards 24, 27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that it has the capacity to maintain an environment to a standard that is satisfactory with the main concern being that there are some areas of poor decoration, however residents and staff confirmed that the environment met their needs. EVIDENCE: A tour of the communal areas of the home was undertaken including living rooms, dining room, large group room and the art room. It was seen that some redecoration is needed in areas for example paintwork is peeling in the dining room, the ceiling (corner) has been water damaged in the large group room and the stairwells in some places have wallpaper and paintwork that is old and tired and needs replacing. Maintenance in general appear to be good, however some improvements are needed including ensuring the art room has a lock as many items stored are Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 20 highly flammable, this room also needs to be kept tidy as there are numerous pieces of old art work. At least two emergency lights were found to be continuously on for no apparent reason. There is a bathroom with a toilet on the top floor, this although basic was seen to be fit for purpose, however the bathroom with a toilet and a shower on the first floor has damaged paintwork including the wooden window sill. It was seen that hand towels are often used in toilets. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 21 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): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not been able to fully demonstrate it has the ability to provide the residents with staff who are adequately recruited and adequately supported to do their jobs. This may mean residents are put at risk and staff may not perform to the best of their ability, which could have a negative impact on the care given to residents. EVIDENCE: Staffing rotas were seen, which recorded that there are permanent staff and sessional staff, their roles included trainee psychotherapists, therapeutic care staff and a clinical team leader. There are two staff rotas, one being a therapeutic staff rota and the second an office rota that includes the registered manager and assistant community manager. The business administrator advised that staffing levels are also flexible, always a minimum two staff on duty with two staff on sleeping duty at night and these numbers can be increased where needed to meet the immediate needs of residents. One resident advised the inspector that there are always staff available should you need them. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 22 Two staff files were sampled including training records. The records indicate that they both had attended required safe working practice training and also refreshers when required. Both staff members had undertaken counselling training to certificate and diploma levels and had competencies in other areas such as records keeping and documentation, risk assessing and breakaway techniques. Requirements of the last inspection were discussed with the assistant community manager and it was agreed that disability training would now not be appropriate, however mental health awareness or similar training would be. The assistant community manager who did complete the pre inspection questionnaire recorded that during the past 12 months five staff had undertaken NVQ level 3 (it was unclear whether this award had been completed) with others to follow and that future training included NVQ level 3 in Health and Social care for the rest of the team. Both staff files included recruitment records. Required checks had been completed including application forms and two written references. There was a list of criminal record bureau disclosures (CRB) containing, the date issued and the disclosure number, the CRB’s for staff recruited after the last inspection were not available. The inspector was advised that there is support available to the staff including supervision. However these appear to be fairly informal sessions with a supervisor available to meet with staff on two days of the week and a more formal supervision once a month. Records of these supervisions were scant and where issues had been raised there was not always an action plan. The surveys returned by the residents included comments about staff such as “this doesn’t mean I agree with everything they do as I don’t, but I know they have my best interests at heart”, “I always feel safe and well treated even if I am frustrated or upset about something”, “I always feel that I have been listened to when I say something and the carers do take action when it is needed” and “mainly I feel listened to, however I don’t always feel it is acted upon as sometimes staff disagree with me and it feels at times that’s the end of the conversation”. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 23 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): Standards 37, 39, 40 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 has not fully demonstrated it has the ability to ensure that the management and administration of the home is always effective to ensure residents are involved in running the service and that it is safely conducted at all times. This may not consider the opinions of residents and may put at risk their health and well being. EVIDENCE: Prior to the key inspection the registered manager forwarded a copy of the level 4 NVQ Registered Managers Award (Adults) awarded to her in October 2006. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 24 The registered manager was not on duty at the time of inspection, she works closely with the assistant community manager who was available and who has recently been recruited. At the time of the inspection the assistant community manager advised of the quality systems used at the home. This included the residents weekly meeting with the staff to discuss any issues. He advised about Connects annual audit by Community of Communities and advised he would forward the results of the most recent self-assessment of the home, this quality assessment has now been received and clearly identifies that a self assessment of core standards, physical environment, staff, joining and leaving, therapeutic environment and external relations is completed. There is also a peer review assessment completed by another Therapeutic Community and results against the same standards are recorded. It is not evident during both processes how the views and opinions of the current residents are gathered and how this information is included within the reviews. The self assessment does not clearly identify what the action plan for improvement. Some of the policies seen recorded that they were written in October 2004 and stated they were due for review on August 2005, for example the very detailed Admissions policy and procedure; there was no evidence of a review. The assistant community manager could not always find some documents about health and safety; he did however forward required documents after the inspection including details of fire drills and water tests. The maintenance records seen at the time of the inspection were mainly up to date, however a current certificate of gas safety (landlord certificate) was not available. The fire officer visited in February 2007 and left several requirements including implementing a step by step fire risk assessment, which was seen to have been partly addressed. The assistant community manager is an appointed fire safety trainer and he had records available for training staff. Other maintenance records were available for electrical safety and servicing and testing of fire systems and equipment. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 2 X 2 X Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 15(1) Requirement The registered person must ensure that all residents have a current written care plan that has been completed in consultation with the residents and / or their representatives. The registered person must ensure where a risk for a resident is identified that a risk management plan be introduced; in consultation with the resident. Timescale for action 30/04/07 2 YA9 12(1) 13(4)(c) 15(1) 30/04/07 3 YA16 12(2)(3) 13(4)(c) 15(1) This must include where required managing finances and health issues and always include a mental health relapse management plan. The registered person must 30/04/07 ensure that “THE RULES” be reviewed and revised, that where a personal risk is identified that individual risk assessments be undertaken with residents. Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 27 4 YA20 13(2) 5 YA24 23(2)(b) (d) 6 YA30 13(3) 7 YA34 19(1)(b)(i) para 1 to 7 of Sch 2. 18(2) 8 YA36 9 YA39 24 10 YA40 17(1)(2) and relevant Schedules. The registered person must ensure that residents who selfadminister their medication have a comprehensive risk assessment in place and that compliance checks are undertaken. The registered person must ensure that areas of the home that require some minor redecoration is completed and ensure there is a programme of work to maintain decoration and repairs in the home. The registered person must ensure that hand washing facilities in toilets are improved to ensure it is hygienic. The registered person must ensure that CRB’s for new staff are maintained at the home until the Commission has seen them. All staff must have, in addition to specialist supervision, recorded supervision at least 6 times a year that reviews performance, training and development. (This requirement was outstanding since the 31/05/05). The registered person must ensure that the system for evaluating the quality of the services at the home clearly includes the views and opinions of the current residents. The registered person must ensure that the homes policies and procedures are subject to regular review and where required revision. 30/04/07 31/05/07 31/03/07 31/03/07 30/04/07 31/05/07 30/06/07 Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 28 11 YA42 13(4)(a)(c) The registered person must ensure that the Gas Safety test (landlords certificate) is up to date and forward a copy to the Commission. 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 29 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 Connect Community DS0000016863.V326514.R01.S.doc Version 5.2 Page 30 - 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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