Inspection on 18/07/06 for 58 Featherstone Road

This inspection was carried out on 18th July 2006.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

58 Featherstone Road 11/07/07

58 Featherstone Road 14/02/06

58 Featherstone Road 04/08/05

58 Featherstone Road 09/03/05

58 Featherstone Road 07/10/04

58 Featherstone Road 12/03/04

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 Featherstone Road, 58 Kings Heath Birmingham West Midlands B14 6BE Lead Inspector Kerry Coulter Unannounced Inspection 18th and 27th July 2006 14:00 Featherstone Road, 58 DS0000016715.V304018.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 Featherstone Road, 58 DS0000016715.V304018.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. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Featherstone Road, 58 Address Kings Heath Birmingham West Midlands B14 6BE 0121 444 6600 0121 443 5968 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) Sense West Care Home 4 Category(ies) of Learning disability (4), Sensory impairment (4) registration, with number of places Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 14th February 2006 Brief Description of the Service: Featherstone Road is a substantial detached home providing spacious accommodation and a specialist service for adults with sensory impairment and learning disabilities. The home is registered for four service users. The home is in a pleasant residential area of Kings Heath close to shops, churches, leisure facilities and Kings Heath Park. The home provides four single bedrooms, three on the first floor and one on the ground floor, and a small office / staff sleeping-in room. Two bedrooms have ensuite facilities and all are individualised to reflect service users personalities. There is a large bathroom upstairs and a toilet downstairs. The lounge is a good size and is comfortable and homely. The house has a large modern fitted kitchen and a dining room. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home, reports from the provider and a pre inspection questionnaire. The unannounced fieldwork visit was carried out over seven and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. Conversations with some service users were limited due to their complex needs and limited verbal communication. The inspector met with all the service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? All staff have had training in preventing abuse so that they know how to protect service users from harm. Some staff have done epilepsy training so they know what to do if a resident has a seizure. Redecoration of the laundry and installation of new garden fencing has made the home a nicer place to live. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 6 The staff recruitment files have been reorganised and now contain all the required information to show that robust recruitment checks are undertaken before staff start work in the home. 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. Featherstone Road, 58 DS0000016715.V304018.R01.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 Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and aspirations are assessed appropriately before an offer of placement is made. EVIDENCE: A referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals. No new service users have been admitted since the last inspection. The home currently has one vacancy. The Acting Manager demonstrated that he was aware of the requirement that new service users are only admitted on the basis of a full assessment undertaken by people competent to do so. A referral has been made for a potential service user to move to the home but as funding has yet to be agreed full assessment has not commenced. However, the Acting Manager said that a meeting has taken place with this individuals relatives to discuss their needs and possible adaptations that would need to be made to the environment. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents needs are generally reflected in their individual plans but some plans required updating. Risk assessments are not available for all areas of risk to fully or accurately underpin residents needs or the risks they face. EVIDENCE: The care provided to two residents was case tracked, this included looking at their care plans. These contained generally detailed information for staff on how individuals should be supported with social skills, personal care, activities, likes and dislikes, meal times, activities, communication and comprehensive health information. Some information on cultural needs had been added and behaviour management guidelines were available where needed. The quality of the plans was variable, for one resident all the plans were up to date but for the other individual they were in the process of being updated. Discussion with the Acting Manager indicates that the Practice Development Worker (PDW) for the home, whose role it is to develop and update the care plans has been off work for some time. A PDW from another SENSE home has Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 10 recently started to provide 16 hours cover a month to assist in reviewing the plans. It was noted that for one individual their care plan needed further information about their cultural needs to include food preferences and culturally appropriate activities. It was positive that when this was raised with the Acting Manager he was able to evidence that he had recently met with the Practice Development Worker and identified these improvements were needed. Each resident has a core team of staff, who meet monthly, to monitor the care plan, progress on achievements, goals, health care and to action any points. Minutes of these core meetings were available in the files sampled. The Acting Manager needs to ensure that at the meeting where actions are identified as needed it is agreed who will carry out the action and when. For one resident it was discussed at two meetings in a row that he needed a lap strap but there was no record of why this was needed and what action was being taken. Members of staff actively encourage each resident to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of objects of reference. Residents records included individual risk assessments. On day one of the inspection visit all residents risk assessments were stored in one very large file with assessments for staff and the environment. This made it difficult to locate individual assessments. It was recommended that the system for filing the assessments was reviewed. This had been actioned by the Acting Manager by day two of the inspection visit. Assessments were in individual files and were easier to access. Generally all the activities that residents participate in had been assessed. One individual likes to spend time on their own playing with stones, they has a supply of these in their bedroom. This needs to be assessed for potential risk of stones being put in their mouth and choking. Several risk assessments had last been reviewed in December 2005 and so were overdue for review. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Planning and recording of activities needs to improve and the food menu reviewed so that people living in the home experience a more enjoyable lifestyle. EVIDENCE: The first day of the inspection visit was reduced in duration due to all residents going out to a country park for a walk. Residents also went out with staff to a park on the second visit to the home. The care plans contained a “Schedule of activity”. Activities on offer included rock climbing, living skills, massage, pudding making, music and shopping. However sampled residents records did not show that the activity planners were being followed and often did not clearly indicate if an activity had been undertaken. Discussion with the Deputy Manager indicates that some activity schedules for residents may be unrealistic and that work is underway to develop new schedules. The Acting Manager was able to provide a draft activity schedule and said that consideration was being given to ensure that activities met individual preferences and cultural needs. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 12 Staff spoken with said that sometimes there were not enough drivers on duty to make full use of the vehicle and enable scheduled activities to take place. The Deputy Manager is trying to address this and was conducting an interview with a potential staff who could drive on the day of the inspection visit. There was evidence that residents are fully supported by staff to maintain contact with relatives. It is an area of good practice that SENSE employs a Family Liason Officer. Regular newsletters are sent out to relatives. Additionally, a family weekend is arranged annually at a local hotel where relatives can meet with SENSE representatives and other relatives. Where restrictions are placed on service users this is linked to risk assessments and care plans. For example, each individual has guidelines for items they will not tolerate in their bedrooms. Care plans sampled stated how staff are to support residents to be as independent as possible. Recording of meals eaten by residents was completed to a good standard. Review of the meals on offer is needed to ensure the menu is varied, nutritious and culturally appropriate. More thought needs to be given to having more home cooked meals rather than the current tendency for pre prepared foods such as pizza. Records showed that meals were sometimes repetitive. Food records did not show that cultural preferences have been taken into account and one residents care plan said that only had culturally appropriate food on ‘special occasions’. The Acting Manager said he was trying to address this by incorporating visits to culturally appropriate restaurants into the weekly activity schedule. Following the inspection sample menus were forwarded to show that review of the meals on offer had taken place. The new menus are more varied and choices better reflect the cultural background of service users. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents generally receive personal support in the way they prefer and require. Records of health appointments need to improve to evidence that residents health needs are being met. Arrangements are in place to ensure that the management of the medication protects residents. EVIDENCE: Care plans contain detailed information on the support needs of residents, and take into account gender care needs. Residents were well dressed appropriately to their age and the very hot weather. Interactions between staff and residents were seen to be warm and friendly, and appropriately respectful. During the visit one residents clothing had ridden up to show their underwear, this was sensitively rectified by a female member of staff. Each resident had an individual Health Action Plan. This is a personal plan about what support a person needs to stay healthy and access the relevant healthcare services. Some plans needed improvement to fully reflect the current support needed. For example, the weight monitoring records for one individual recorded that they had put on a stone in weight in the last twelve Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 14 months. The health action plan did not record if any investigations for this had been done or if the option of more healthy eating needed to be explored. Whilst it was evident that residents are supported to attend annual health checks it was difficult to properly track these as staff were not using the health action plan forms but were instead continuing to use the previous health records, so effectively there were two sets of records being used. One resident had seen the GP for an ear infection where a swab had been taken, records sampled did not show what the outcome of this had been. Medicines were seen to be stored appropriately in a secure location. A random audit of stocks held revealed no discrepancies, and there were no gaps on the administration record. Where residents are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. Information to guide staff as to the signs of the individual being in pain/distress had been included as required at the last inspection. Sense have a medication policy in place that requires staff to have a regular medication competence assessment completed. These were observed to have been done by the Acting Manager. The majority of staff have completed medication training, those who require it are booked to attend in September and November. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints are satisfactory to ensure that residents views are listened to and acted on. Arrangements are sufficient to ensure that residents are protected from abuse. EVIDENCE: The homes complaint procedure includes information on the role of the CSCI in investigating complaints and is available in a picture format and CD Rom. Some of the residents due to their complex needs are not able to make a complaint and are reliant on staff, relatives or an advocate to act on their behalf. CSCI had investigated no complaints from residents or any other source in respect of this home in the past twelve months. Copies of the Birmingham Multi Agency Adult Protection guidelines and the homes adult protection flowchart were observed to be readily available to staff. The home has a written prevention of abuse policy that is robust. Records show that staff have received training in adult protection. Since the last inspection there has been two separate adult protection matters notified by Sense to the CSCI. Sense has dealt with both of these matters in line with the multi agency adult protection guidelines. One incident resulted in a member of staff being dismissed, the other is still under investigation. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Maintenance and redecoration work has been scheduled to ensure that the home remains a pleasant place for resident to live. EVIDENCE: Featherstone Road is a domestic style house that is in keeping with houses in the locality. The home was clean and free from offensive odours. The condition of the décor, fixtures and fittings was quite variable and several areas of the home required attention to make sure the home remained a pleasant place for residents to live. However work has been undertaken by the staff team to complete a maintenance plan for the home. The plan is very comprehensive and covers the repairs needed. This inspection was conducted over two days, in between visits work had commended on replacing the rear garden fencing as it was damaged and rotting in places. It was identified at the last two inspections that the lounge Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 17 carpet was badly stained and required replacement. Although this has not yet been done new carpet samples had been obtained and the Acting Manger said that a new carpet was soon to be fitted. The staff bathroom is adequate for its purpose but it was identified at the last inspection that the décor is quite worn, and it was recommended that it is redecorated making it a more pleasant facility for staff. The Acting Manager said that Sense has agreed that this will soon be done. Since the last inspection the laundry has been repainted as the walls had become quite stained. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing and their support and development are generally sufficient to ensure that an effective staff team supports residents and meets their individual needs. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: It was noted that both staff and residents appear comfortable in each other’s company, staff give support with warmth, friendliness and patience and treat people respectfully. It is a strength of this home that many of the staff have worked there for some time, residents are therefore supported by staff who know them well. The training matrix for the home shows that six staff have completed an NVQ care, this meets the standard of having at least 50 of staff NVQ trained. The home has been a short staffed recently due to staff sickness and other staff absences. The deficits in staffing have been covered by staff working extra hours or the use of casual staff. The use of agency staff has been kept to a minimum. During the day there are generally two staff on duty to meet the needs of the three residents. Staff spoken with said that the number of staff were adequate but some had concerns that two staff would not be enough if Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 19 anther resident moved into the home. Discussion with the Deputy Manager and General Manager indicates a staffing review would take place prior to a new resident being admitted to the home. Staff recruitment files were sampled, these were seen to be very well organised. They contained all the information as required by regulation to include satisfactory evidence that a CRB check had been obtained so that residents are protected by a robust recruitment procedure. Observation of the staff training matrix shows that Sense has a rolling programme of training for staff but that some staff have missed out on some areas of training or need refresher training. Most staff have recently undertaken adult protection and fire training. Where staff need mandatory training the Deputy Manager is ensuring that staff are booked onto the training they need. It was identified at the last inspection that staff needed training in epilepsy to ensure they could meet the specific needs of residents, three of the staff team received this training in February. The Deputy Manager hopes to arrange training on epilepsy for staff who were unable to attend the February session. Forthcoming training planned for staff includes issues of bereavement. Staff spoken with were generally satisfied with the quality of the training on offer but one did comment that the location of training events could sometimes mean extra travelling. Supervision records for three staff were sampled, these showed that the quality of supervisions is good and the frequency regular to ensure staff are well supported in their job role. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The Acting Manager has improved the management arrangements to ensure that residents benefit from a well run home, registration of a permanent manager with the CSCI will ensure that management arrangements are consistent. EVIDENCE: The management of this home has undergone many changes in personnel. The current manager of the home is currently off work and an acting manager is in place who has transferred from another Sense home. An application to register a manager for the home has therefore not been made as previously required. The Acting Manager who has only been in post a short while has already started to implement some positive changes in the home. Where shortfalls have been identified as part of the inspection process the Acting Manager was already aware of most of the issues and had plans to improve things. Whist the staff team were complimentary about how the Acting Manager was running the Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 21 home some spoke about the negative effect that the constant change in managers had on things and said that when new managers start things keep getting changed. One staff commented that they were sure that in the last nine years the home had nine managers. Whilst the current manager situation in the home is one that is not the fault of the organisation , Sense must ensure that the future management arrangements at the home remain stable so that staff have a clear sense of direction and are confident that changes made will not be changed again if a new manager starts. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are also carried out periodically to include health and safety, financial, environment and outcomes for residents. Sense as an organisation has also developed a staff development plan that covers induction and staff training. Records were kept up to date and were generally satisfactory. Some were of a good standard to include food records and staff recruitment files. A minority of residents records sampled were not descriptive about residents behaviour. One record sampled said, “ Has had outbursts today” There was no further detail about the actual behaviour or how they were supported. As detailed earlier in this report attention is also needed to the quality of recording regarding residents activities and health monitoring. The certificate for the electrical installations in the home said they were unsatisfactory, proof that the required work had been done make these safe was not available. The acting Manager said that he was arranging for a new check to be done and any work required would be completed. The homes fire records were observed, these indicated that regular testing of the alarms and emergency lighting is generally carried out. Certificates of servicing were available for the fire alarms. A recent service done at the end of June had recommended that old detectors were replaced, the Acting Manager said this was being organised. Records evidence that a recent fire drill had been conducted. The Acting Manager said that he had arranged for a water survey of the home to be done the following day, to check for the risk of legionella. Evidence was later sent to the CSCI to show this had been done. Up to date detailed risk assessments for the premises, risk of fire, staff and food had been completed. Staff test the water temperatures regularly, these show the water is maintained at a safe temperature. Fridge and freezer temperatures are tested to ensure food is stored at the correct temperature. Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 22 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 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 2 13 2 14 X 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 3 X 2 2 X Featherstone Road, 58 DS0000016715.V304018.R01.S.doc Version 5.2 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14 Requirement Ensure all care plans are reviewed at least six monthly. Outstanding requirement from 31/03/06. Care plans must set out in detail the care required to be carried out by staff to ensure all needs of residents are being met, to include cultural needs. Risk assessments must be developed for all residents assessed and identified areas of need, and must be reviewed at least six monthly. Review the arrangements for activity opportunities for residents to ensure they are realistic, varied and activities undertaken are in line with activity plans. Menu planning must be reviewed to ensure residents receive a balanced, varied, culturally appropriate and healthy diet. Ensure the recording of health care is improved to enable healthcare of residents to be satisfactorily tracked. Lounge carpet- stains must be DS0000016715.V304018.R01.S.doc Timescale for action 30/09/06 2. YA6 14 30/09/06 3. YA9 13(4) 30/08/06 4. YA12 YA13 16(2)(m,n) 30/09/06 5. YA17 12(1 a) 16(2 i) 30/08/06 6. YA19 12(1)(a) Sch 3 (3) (m) 23(2) 30/08/06 7. YA24 30/08/06 Page 24 Featherstone Road, 58 Version 5.2 8. 9. YA35 YA37 18(1)(c) 9 removed or the carpet replaced. Outstanding requirement from 30/06/06 Ensure all staff have completed 30/10/06 all the training they need to meet residents needs. An application for registration 30/10/06 for a manager needs to be made to the CSCI. Outstanding from 31/03/06 but due to present circumstances Sense have been unable to comply. Ensure staff complete records 30/08/06 required by regulation in a satisfactory manner. An electrician must ensure that 30/09/06 the electrical installations in the home are satisfactory. A copy of the certificate to evidence this must be forwarded to the CSCI. Copy of certificate received by CSCI following inspection. 10. 11. YA41 YA42 17 Schedule 3 13 (4) (ac) 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 YA24 Good Practice Recommendations The staff bathroom is adequate for its purpose but the décor is quite worn, it is recommended that it is redecorated making it a more pleasant facility for staff. Previous recommendation. Risk assessments. It would be beneficial if evidence of evaluation of the assessments was recorded on the review sheet in addition to the current system of staff just signing to say they had been reviewed. Previous recommendation. 2. 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