Inspection on 20/12/06 for FCH Southbrook Road

This inspection was carried out on 20th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

FCH Southbrook Road 23/11/05

FCH Southbrook Road 06/06/05

FCH Southbrook Road 25/11/04

FCH Southbrook Road 30/06/04

FCH Southbrook Road 18/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 FCH Southbrook Road 3/4 Southbrook Road Rugby Warwickshire CV22 5NS Lead Inspector Patricia Flanaghan Key Unannounced Inspection 20th & 28th December 2006 11:45 FCH Southbrook Road DS0000004325.V317849.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 FCH Southbrook Road DS0000004325.V317849.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. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service FCH Southbrook Road Address 3/4 Southbrook Road Rugby Warwickshire CV22 5NS 01788 816928 01788 816928 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) FCH - Housing and Care Mrs Lydia Shallcross Care Home 6 Category(ies) of Learning disability (6) registration, with number of places FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 November 2006 Brief Description of the Service: 3/4 Southbrook Road is a registered care home for six younger adults with learning disability. FCH Housing and Care, (FCH), provides 24 hour care and support for the service users living in the home. The home provides two separate living accommodations each providing a living environment for three service users. The living accommodation at 3 Southbrook includes a lounge, with dining area, kitchen, bathroom and three individual bedrooms. Living accommodation at 4 Southbrook includes a lounge, kitchen with dining area, bathroom and three bedrooms, one of which is situated on the ground floor and has an en-suite facility. There is a shared laundry area connecting the two houses. The service is situated on the outskirts of Rugby town centre and close to a small shopping precinct, and other local facilities. There is a parking area to the front of the property and a large landscaped, accessible shared garden to the rear of both houses. Access can be gained to each house independently and there is third entrance for staff coming on duty. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This unannounced inspection visit took place over two days on Wednesday, 20th December between 12.30pm and 3.00pm and Thursday 28th December between 11.00am and 4.00pm. Two service users were ‘case tracked’. This involves establishing an individual’s experience of living in the care home by meeting or observing them, discussing their care with staff, looking at their care files, and focusing on outcomes. Records including staff files, policies and procedures, health and safety and risk assessments were also examined. The manager of the home completed and returned a questionnaire containing further information about the home as part of the inspection process. Some of the information contained within this document has also been used in assessing actions taken by the home to meet care standards. Time was spent in both houses with the service users and staff. It was not possible to ask all service users directly for their views of Southbrook Road, due to their communication difficulties. Instead their interactions with staff and other people and daily life routines were observed. Several staff (one who was new) were spoken with individually about service users’ care, their own training and experience and other relevant aspects about how the home is run. The inspector would like to thank service users and staff for their cooperation and hospitality. What the service does well: Both houses are comfortable, clean and homely and reflect the individual needs and personal preferences of the service users. Observations made during the inspection showed that there was a good rapport between the service users and staff. During the inspection staff interacted with the service users in a way that promoted the service users independence, respected their privacy and dignity and enabled the service users to make a valued contribution to the running of the home. All of the documents seen were well ordered, easily accessible and up to date. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 6 Recorded information about service users is detailed, person-centered and provides staff with clear guidance on service users’ needs, goals and wishes. Service users’ health needs are monitored and well met with the support of the staff. Staff receive a high level of training and support to ensure service users’ needs are met safely and consistently. The service users continue to be able to participate in a broad range of activities that reflect their personal preferences, promote their independence and that they enjoy. The environment is decorated and furnished to a good standard that creates a homely atmosphere. The home is managed well and has a consistent, experienced staff team. To ensure the home is run in the best interests of service users, systems are in place that seek the views of service users, staff, relatives and outside stakeholders on the quality of the service. One relative wrote in the visitors book “….it was great to see (service user) so well and so happy. My thanks to all the staff.” There are excellent systems in place to ensure that service users’ and staffs’ safety, health and welfare are fully protected. What has improved since the last inspection? What they could do better: There were no requirements made as a result of this inspection visit. A good practice recommendation was made for the organisation to develop a procedure to ensure staff recruitment records in the home are readily available for inspection. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. FCH Southbrook Road DS0000004325.V317849.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 FCH Southbrook Road DS0000004325.V317849.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): X EVIDENCE: These standards were not fully assessed, as no new service users have been admitted to the home for a long-term placement for some time. The manager confirmed that any new people referred to the home would be provided with a full assessment and have opportunities visit and meet with any resident living the in the home before they move in. An appropriate pre-admission assessment was seen. The standards within this section have been met at previous inspections. FCH Southbrook Road DS0000004325.V317849.R01.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 excellent. Resident’s rights are respected and risks are assessed to ensure service users have guidance and support to lead as independent a life as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of service users care files were examined. These were well ordered and contain clear and concise information that details the service users needs and how these are met. Service users are fully involved in the information in their care plan. Information includes, personal details, a pen picture, daily care plan, needs assessments, guidance, monthly summaries, appointments, risk assessments, action sheets and manual handling assessments. Observations during the inspection confirmed that the care plans are implemented. Discussions with a number of staff confirmed that they have a sound understanding of each individual service users needs and how the service users prefer these to be met. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 11 Risk assessments have been completed and strategies in place to reduce the risks identified. Both care plans and risk assessments are reviewed regularly at planned intervals or as the service users needs change. Observations during the inspection, discussions with staff and service users and examination of records confirmed that the service users continue to be enabled to make decisions that affect their every day lives. The staff use a variety of communication techniques to facilitate this. The technique used is thus dependant upon the needs and abilities of the individual service user. The staff demonstrated a sound knowledge of each individual service users preferred method of communication; this is also documented in their care plan. There is an established system in place for key workers and service users to meet quarterly to discuss care plan progress and key workers complete a report of the activities each week that have taken place to meet individual needs. The manager monitors both key worker meeting and activity documents on a regular basis. It was clear through talking with service users, the evidence gathered and observations made, that the manager and staff are committed to providing care that is person-centered. Staff receive a good level of training that helps them to understand and meet service users’ needs. FCH Southbrook Road DS0000004325.V317849.R01.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 excellent. Service users have a good lifestyle with the ability to participate in house and community activities, encouragement to maintain contact with friends and family, and have a choice of food they like. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of each of the houses confirmed that the home provide a broad range of activities to do at home. The service users are able to pursue their hobbies. Service users use the local community for shopping, going to the library, cafes and pubs. Service users have the opportunity to go on two annual holidays and these can be abroad if that is what the service user chooses. One of the service users showed the inspector photographs of a recent holiday she had enjoyed at Euro Disney. Service users have enjoyed holidays in Weymouth, Great Yarmouth and Blackpool in the past twelve months. Regular day outings FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 13 are also undertaken, for example, service users enjoyed a canal barge outing, a London Musical and a rock concert during the year. On the day of the inspection most of the service users attended their day services or work placement activities returning home late afternoon. There was evidence that the staff team coordinate with day service staff and college tutors in working together to achieve the aims and expectations of each individual service user. The service users were seen to move freely around the communal areas of their home and were able to choose when to spend time alone. It was pleasing to note that the service users and staff did not access the other houses without being invited. The philosophy at Southbrook Road is very much about encouraging and supporting independence. The home is run in a person centered way by consulting service users in decisions about their lives and the running of the home. There are service users meetings held where all people are invited to attend and share their views about the home. Records and photographs of these meetings are available for staff and service users to refer to. Records examined and discussions with service users and staff confirmed that the service users are supported to receive visitors or to visit their family. The staff confirmed that family and friends are invited to special occasions and parties arranged by the home. The support service users need to maintain family links and friendships, inside and outside of the home, is clearly identified on their care plan. There is evidence in the home from photographs, diary entries and letters from family members of their involvement in activities and lifestyle of the people living in the home. Service users can access all shared areas of the home and were seen to do so freely. Staff were observed to knock before entering service user’s bedrooms and respected their privacy by not going into their bedrooms if the service user was not at home. The Inspector observed staff and service users speaking with each other in a friendly manner, giving time and space to the person speaking and respecting what they said. Discussions with the staff and service users and examination of records confirmed that the service users are able to choose the meals that are provided. Each bungalow holds a weekly meeting where the service users are shown pictures of a selection of meals that they can choose from. The staff said that they take into consideration the service users likes and dislikes and special dietary requirements. These are recorded in the service users plans. The menu plans seen confirmed that the service users have a varied diet. A variety of drinks and snacks were available for the service users. Observation during the inspection confirmed that the service users meals are prepared in a way that enables the service users to maintain independence. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 14 Specialist crockery and cutlery is provided. Some service users require staff support to eat and drink; this support was given in a sensitive way that promoted the service users dignity. The level of support required is detailed in the service users plans. The staff confirmed that alternative meals are provided if a service user indicates that they don’t like the meal that is available. Observations during the inspection and discussions with the service users confirmed that the service users like their meals. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is excellent. The service users personal and healthcare needs are met in a way that reflects their preferences, promotes their privacy, dignity and independence and is responsive to changes in the service users needs and wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users files examined contained detailed information as to how the service users prefer their personal care needs to be met. From discussion with staff about how the service users needs are met it was evident that the staff have a sensitive approach to the provision of personal care, and are aware of privacy, dignity and independence issues. Routine health care checks are arranged, as well as input, appointments, and treatment provided from health care specialists. Each resident has a separate book provided by the local Primary Care Trust (PCT) where all contact with health care professionals are recorded. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 16 Observations during the inspection confirmed that the service users are supported sensitively in a way that promotes their dignity and well being. The staff demonstrated that they provide care in a flexible way that responds to the service users changing needs and wishes. Throughout the inspection the service users appeared to be relaxed and comfortable. The two medication records examined were up-to-date and in good order. This included a correct balance of medicine held in the home against the Medicine Administration Record, (MAR), chart and full directions and dosages being recorded on the MAR chart. There was a copy of the current GP prescription for the service user on each medicine file. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Suitable arrangements are in place for the effective management of complaints and to ensure the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are processes in place for service users to express their concerns and make a complaint if they wish to do so. Information regarding the complaints procedure is available to service users in written and audio format. The service users are given opportunities to raise concerns or make suggestions informally at monthly house meetings. There is evidence that suggestions made are acted upon. The communication needs of service users are known and care practice observed demonstrated that staff had a good knowledge and understanding of how people communicated their wishes and choices. The manager confirmed that the home has not received any complaints since the time of the last inspection. The Commission for Social Care Inspection has not received any concerns or complaints about this service. Discussions with the manger and staff confirmed that they are aware of their responsibilities in the event that concerns that are raised or a complaint is made. Staff demonstrated an excellent understanding and awareness of abuse; they were able to describe many types of abuse, including financial, verbal, physical, psychological and using medication inappropriately. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 18 Staff develop a knowledge and awareness of vulnerable adult issues through attendance at Learning Disability Award Framework during their induction and also access specific training in the Protection of Vulnerable Adult Policies and Procedures (POVA). The home has adult protection policies and procedures, including the local multi-agency procedures, which staff were aware of. The home has good financial procedures that protect service users from potential financial abuse. Records relating to the service users finances were examined and were in order. FCH Southbrook Road DS0000004325.V317849.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): 24, 25, 26, 27 and 30 Quality in this outcome area is good. The standard of the environment is high providing the service users with a safe, clean, comfortable and homely place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both houses were clean, bright, comfortable and homely. There is a large garden to the rear of the property with a patio area. Service users are encouraged to participate in gardening activities and to buy equipment and garden furniture if they wish. Photographs seen on house meeting records show service users enjoying gardening activities. The home is maintained to a high standard. The manager confirmed that there is a plan in place to redecorate some areas of the home that have been damaged by the service users wheelchairs. This is proactive, as the level of damage that has been caused does not currently detract from the overall appearance of the home. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 20 The bedrooms are furnished, decorated and personalised to reflect the individual personalities of the service user to whom they belong. Bathrooms are fitted appropriately with sufficient aids and adaptations necessary to meet assessed needs. This includes bath chairs, adjustable bath/showering facilities and removable bath panels to enable safe hoisting. Since the last inspection both bathrooms have been redecorated and had new flooring fitted. Discussions with the staff and observations during the inspection confirmed that the home has appropriate procedures in place to reduce the risk of cross infection. Hand washing facilities are available in the kitchen and laundry and appropriate cleaning materials and equipment were available. The houses share a large laundry room. The laundry facilities are appropriate for the needs of the home. They consist of an industrial washing machine, which has a facility to wash items at high temperatures if required and an industrial tumble dryer. Cleaning materials were stored securely. FCH Southbrook Road DS0000004325.V317849.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): 32, 34 and 35 Quality in this outcome area is good. The service users benefit from receiving support from an experienced staff team, who have the knowledge and skill to enable them to meet their needs effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet the service users needs and to facilitate activities. Three to four staff members were on duty in each house throughout the day. The manager is supernumerary to the staffing rota. The staff and manager confirmed that these staffing ratios are the norm for the home and that staffing ratios are increased to enable planned activities to take place. Examination of records relating to the service users needs and to staff training and discussions with staff confirm that the staff have received training that is appropriate to their role. This includes training relating to Dementia Care, Principles of Care Practice, Protection of Vulnerable Adults, Health and Safety, FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 22 Makaton Communication and Equality and Diversity. This is in addition to mandatory training in Medication Administration, Food Hygiene, Manual Handling, Fire Safety and First Aid. There is evidence that this training is reviewed at regular intervals. Management discuss individual training needs with staff at monthly supervision meetings. There continues to be an active NVQ programme in place and staff have completed the core Learning Disability Award Framework training. Recruitment takes place at the central offices of Friendship Care and Housing with the manager of the service being involved in the interview process. Due to unforeseen circumstances the recruitment files of recently employed staff were not available for examination. A discussion with the manager demonstrated that she is aware of the procedures to be followed and assured the inspector that all necessary pre-employment checks are in place for each staff member. A recently employed staff member said that the home had taken up references and a Criminal records Bureau (CRB) check before confirming her appointment. The organisation should consider implementing a procedure to ensure staff recruitment records in the home are readily available for inspection. Recent inspections of this service have demonstrated that the home follow robust procedures when recruiting new staff members. The staff and manager demonstrated throughout this inspection that they have a clear understanding of their roles and responsibilities and have the necessary skills and ability to perform their roles effectively. It is clear that positive relationships have been formed between the service users and staff. FCH Southbrook Road DS0000004325.V317849.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): 37, 39 and 42 Quality in this outcome area is excellent. Service users benefit from a home that is well managed, ensuring the home is run in service users’ best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has many years of experience in care and is awaiting verification from the training provider that she has successfully obtained the Registered Manager’s Award qualification. To support the manager, the home has a deputy manager, who will also shortly be registering on the Registered Manager’s Award. Staff said they receive excellent support from the senior support worker and management. They receive regular one-to-one supervision and guidance when necessary. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 24 The home has many systems in place to assess the quality of the services provided. In July 2006 Southbrook Road consulted staff, service users, relatives and health professionals to ensure their views on how the home is run were sought and they were satisfied. Any concerns or comments raised are dealt with to ensure there is complete satisfaction. A clear action plan was produced on how to improve services. Comments seen from relatives on the returned questionnaires include: • • • “…is given a very full and varied lifestyle while respecting her needs and wishes.” “…this is down to the excellent work the staff put in.” “…the whole family are extremely pleased with the standard at Southbrook Road.” Service user meetings take place every month to ensure they are consulted about how the home is run and have the opportunity to raise concerns. These confirmed that the service users have the opportunity to contribute to the running of the home, choose meals and activities and identify health and safety issues. There is evidence that the suggestions made by the service users are acted upon. To ensure regular checks and work is completed, the home has a monthly check list for staff to follow, for example, monthly service user reports, service users’ meetings, cleaning rotas and checks on smoke detectors, first aid kits. Staff are appropriately trained to ensure they are suitably competent to meet service users’ needs. Staff have an excellent knowledge of service users’ needs and risks and described how to prevent and manage service users in distress. The manager provided information prior to the inspection though a questionnaire, which included conformation that all necessary policies and procedures were in place and are up to date. These were not inspected on the day of the inspection, but the information was used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. These policies, along with risk assessments, are reviewed regularly and are updated where necessary, to ensure they are appropriate and reduce risks to staff and service users. The manager monitors that the staff are fulfilling their roles during staff supervision and appraisal meetings. A sample of records relating to the health and safety of the home were examined. This along with information provided in the pre-inspection questionnaire and observations during the inspection confirm that the home takes appropriate action to maintain the health and safety of the service users and staff. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 25 FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 26 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 X 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 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 4 X X 3 X FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA42 Good Practice Recommendations The organisation should develop a procedure which ensures staff recruitment records in the home are readily available for inspection. FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 FCH Southbrook Road DS0000004325.V317849.R01.S.doc Version 5.2 Page 29 - 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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