Inspection on 13/11/06 for Giles Shirley Hall

This inspection was carried out on 13th November 2006.

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

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

Other inspections for this house

Giles Shirley Hall 13/07/09

Giles Shirley Hall 12/12/07

Giles Shirley Hall 11/03/06

Giles Shirley Hall 20/09/05

Giles Shirley Hall 29/04/04

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

CARE HOME ADULTS 18-65 Giles Shirley Hall York Street Bromborough Pool Wirral CH62 4TZ Lead Inspector Beate Roth Unannounced Inspection 13 and 23 November 2006 10:00 th rd Giles Shirley Hall DS0000028492.V314559.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 Giles Shirley Hall DS0000028492.V314559.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. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Giles Shirley Hall Address York Street Bromborough Pool Wirral CH62 4TZ 0151 643 5563 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) Wirral Autistic Society Mrs Siobhan Anne Wise Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th March 2006 Brief Description of the Service: Giles Shirley Hall provides personal care for eleven adults with autism. The home consists of four flats, which are accessible to one another and share the same main entrances. All bedrooms are single and have en-suite facilities. Each flat has a communal area comprising of a domestic style kitchen and dining/lounge area. There are gardens to the front and side of the home. The home is reasonably close to local shops and to public transport services. Parking is available on the main road. The home is run by Wirral Autistic Society who have several care homes for adults with autism in the area. Wirral Autistic Society provides a range of day services and facilities, which are fully utilised by the service users, accommodated at Giles Shirley Hall. At the time of the inspection, the weekly cost for the service ranged from £883.00 to £1408.00. A copy of the statement of purpose, which describes the services offered at Giles Shirley Hall, is made available to relatives and social workers. The service users guide to the home is made available before a service user comes to live at the home and the content is discussed with them to ensure their understanding. The home is contained within a converted village hall. Wirral Autistic Society has a conference hall and technology suite also housed within the building. These facilities are open to the general public. There is a separate point of access to the building for the general public. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 8 hours and is based on a visit to the home and a visit to Wirral Autistic Society’s personnel department to view the records of recruitment. The inspection is also informed by information received about the service since the last inspection and by questionnaires completed by the manager, service users and their relatives. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with service users and staff. What the service does well: What has improved since the last inspection? What they could do better: Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 6 Improvements are needed to the records kept of meals in order to demonstrate that varied and well-balanced meals are provided. A risk assessment around service users going out without staff support needs to clearly indicate how this decision was reached and the safeguards in place to support the service user. A record of the action taken to investigate a complaint needs to be clearly documented. Improvements are needed to the arrangements for keeping the communal carpets clean. Service users would benefit from further staff completing a relevant NVQ in care or equivalent. 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. Giles Shirley Hall DS0000028492.V314559.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 Giles Shirley Hall DS0000028492.V314559.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, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The assessment process ensures that the service is only offered to individuals whose needs can be met at the home. Service users are able to make several visits to the home to make sure it is right for them before moving in. The contracts/terms and conditions support the interests of service users. EVIDENCE: No new service users have come to live at the home since the last inspection. New service users are assessed by the manager for the home and by a representative from day services. The manager visits a prospective service user where they are living. Information is gathered from the service users’ carers, social worker and any other relevant agencies. An examination of an initial assessment at the last inspection indicated that a thorough assessment is completed that meets the National Minimum Standards for Care Homes for Adults. If a service user moves to the home from another home run by Wirral Autistic Society, an assessment of the service users needs is undertaken. New service users can make a number of visits to the home to get to know the service, meet the staff and other service users. These visits are planned in accordance with the needs of the new and existing service users. Parents/carers and representatives from placing authorities are also able to make visits to the service. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 9 A sample of contracts/statement of terms and conditions between the home and the service users were seen. These documents contain the required information and indicated that a representative of the service users had been involved in the drawing up of this document. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. In general, care planning reflects the assessed and changing needs of service users. Improvements are needed to a risk assessment in order to ensure that staff have access to clear guidance. EVIDENCE: Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 11 Three service user plans were examined and contained detailed and clear information to enable staff to provide appropriate support around day-to-day living and personal goals. Care plans take into account the religious and cultural needs of service users and how these needs are to be met. A review of the service user plans had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to reviews. Records showed that the needs of service users are closely monitored in order to ensure that their needs continue to be met within the service. An examination of the service user plans indicated that service users’ rights to live as independently as possible, in accordance with their abilities, is promoted by the home. Risk assessments are available which indicate why service users’ rights need to be limited in order to safeguard their wellbeing. At the last inspection the risk assessment for a service user around staying in the home without staff and going out without staff support did not contain sufficient information around how staff were to meet the needs of this service user. At this inspection these risk assessments had been completed, however the risk assessment around the service user going out without staff support did not contain enough information to give clear guidance to staff. At the last inspection a requirement was made that a risk assessment was needed around staff transporting service users who can display challenging behaviour. This had been completed at this inspection but did not contain sufficient information. This was addressed during the inspection. Reactive plans, which detail behaviour management strategies are available. These indicate that as a last resort physical intervention is used. The records made following an incident of physical intervention were satisfactorily maintained and indicated that physical intervention is not used frequently. Care needs to be taken to ensure that the exact method of physical intervention is documented as one record did not clearly reflect this. Since the last inspection, all staff apart from 2 new staff have been trained in non-violent crisis intervention training. An accredited trainer is providing this instruction to staff. Relatives who completed questionnaires made very positive comments about the care provided. Relatives reported that they are consulted about their relatives care and kept informed of important matters. Service users are encouraged to contribute towards the running of the household. Service users tidy and clean their bedrooms, go shopping and help with meal preparation in accordance with their abilities. Service users’ views are obtained through their individual key and link workers. Service users spoken with were happy with the care provided. Observations indicated that service users are relaxed with staff and approach staff with any support issues Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 12 they may have. Staff are trained in meeting the needs of adults with autism during their induction, the induction also covers health and safety issues and promoting equality and diversity within the service. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. Links with the local community are promoted. The daily routines and arrangements for promoting relationships with family and friends, support service users. Improvements are needed to the records kept of meals in order to demonstrate that varied and wellbalanced meals are provided. EVIDENCE: Service users attend day services run by Wirral Autistic Society, where they are provided with a range of opportunities to promote their personal development. Service users have a timetable of activities, which has been drawn up to meet their needs, skills and individual preferences. Some of the opportunities available are horticulture, craftwork, drama and physical education. Service users attend local colleges and are provided with work experience opportunities in accordance with their abilities. A review of these activities takes place to ensure they meet the needs of each service user. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 14 Records and staff and service users said that there are opportunities for service users to become involved in the local community. Service users go out to local shops, leisure facilities and use public transport. The home has access to private transport. Service users go out independently following a risk assessment. Records indicated that family links and friendships are promoted. The arrangements for contact with family are written into the service users’ care plans. Service users have the opportunity to meet people and make friends with people who do not have their disability, through attendance at social clubs and through community activities. Questionnaires completed by relatives indicated that they can visit their relatives in private. Discussions with the staff and observations confirmed that the home’s routines are flexible as much as possible and fit in with the needs and wishes of the service users. The records inspected indicate service users skills and the support service users need in their daily lives in order to make decisions and encourage independence. Care plans indicate the dietary requirements of service users. Advice is obtained from a dietician if this is required. A record is kept of meals provided to service users. Some records of food provided did not contain enough information to show that the meals are healthily balanced. The manager had already identified this and was taking steps to address this. A service user spoken with said that they help choose the meals and do the shopping and cooking with staff support. Each flat has a domestic style kitchen and dining area that provide a homely atmosphere in which to enjoy meals. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The personal care and health needs of service users are well met. Service users are safeguarded by the home’s procedures and policies for the management of medication. EVIDENCE: Records detail the support service users need with their personal care. Observations indicated that staff, promote the privacy and dignity of service users. Staff receive training on promoting privacy and dignity during their induction. Consistency and continuity of support for service users is provided through the key worker system. Since the last inspection a link worker has also been introduced in response to suggestions made by parents/carers. Where possible either the key worker or link worker are now available on duty to respond to any issues raised by parents/carers, health and placing authorities. Although service users have a key and link worker they can approach any member of staff for support in accordance with their care plan. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 16 Records of reviews and a discussion with a service user indicated that service users have access to medical/health care professionals as needed. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A medication procedure is available which provides clear guidance. Medication is stored securely. Staff receive training in the safe handling of medication from the pharmacist who supplies medication to the home. Training in the home’s medication procedure is provided in-house. Two members of staff interviewed who administer medication reported that they have received this training. A selection of medication administration record sheets and corresponding medication were inspected and found to be in order. A risk assessment is undertaken before service users take responsibility for administering their medication. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. Service users are safeguarded by the complaints process and the practices at the home provide protection for service users form abuse. Improvements are needed to the records kept of investigations into complaints. EVIDENCE: Information is available to enable a complaint to be made by a service user or on their behalf, by an advocate. The complaint procedure includes the timescales for dealing with each stage of a complaint. The complaint procedure is displayed on the service users’ notice boards. The procedure is available in different formats to reflect the abilities of service users. A record is kept of any complaints made. The records indicated that since the last inspection one complaint had been made by two service users concerning the same issue. The record of complaints did not indicate the action taken to address the complaint. This was brought to the attention of the manager to be addressed. A discussion with the manager and a service user concerned indicated the action taken to address the complaint. A service user who spoke to the inspector said that if they wanted to complain or comment about any aspect of the service they receive at the home they would know how to do so. Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 18 A copy of Wirral Borough Council’s adult protection procedures was available at the home. A shorter and more accessible version of the adult protection procedure has been made available by Wirral Borough Council and was at the home for staff to refer to. The manager reported that all staff who work at the home have received training in the adult protection procedures. Records show that adult protection issues are appropriately managed. An examination of the financial records held at the home and a discussion with staff indicated that the home’s policies and practices with regards to service users’ money safeguard service users. Monies held on behalf of service users are checked daily by staff, audited by the manager on a monthly basis and by the representative of the registered provider at their monthly visits. Receipts are maintained and records are signed by staff. At this inspection a member of staff had identified a minor error in the financial records, systems were in place to resolve this issue during the inspection. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. The home in general provides a comfortable and pleasant environment for service users. Improvements are needed to the arrangements for keeping the communal carpets clean. EVIDENCE: Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 20 The home is in general well maintained. Since the last inspection some of the paintwork has been refreshed. However, some of the paintwork in the communal areas continues to show signs of wear and tear. The premises are accessible to all service users. The home offers access to local amenities, transport and relevant support services. Furnishings, fittings and equipment are of a good quality. The home is contained within a converted village hall. Wirral Autistic Society has a conference hall and technology suite also housed within the building. These facilities are open to the general public. There is a separate point of access to the building for the general public, which the manager has reported at previous inspections, is only open when the community facilities are being used. A homely atmosphere is not promoted by public facilities being housed within the same building. The manager is keeping under review the risk assessment of public access to the building and service users accessing the public areas of the building. An inspection of a sample of bedrooms indicated that good quality furnishings and fittings are provided. Service users have individualised their bedrooms. Each bedroom has en-suite facilities. Service users spoken with reported that they are pleased with the amenities and space provided. A tour of the home showed that the home was, in general clean. A couple of carpets identified with the manager were stained. This staining appeared to have developed over time. The manager reported that these carpets are due to be cleaned. Carpets are cleaned as and when needed rather than having a rolling programme of cleaning which would maintain good standards of cleanliness at all times. The manager reported that care staff are responsible for keeping the home clean. The manager is currently looking at deploying domestic staff to carry out these duties. It is recommended that steps are taken to identify a system for ensuring that the communal carpets are kept clean at all times. There are procedures for staff to refer to about hygiene and infection control. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including visiting the service. Service users are supported by competent staff who have access to good training opportunities. Service users would benefit further if 50 of staff had completed an NVQ in care or equivalent. In general staff are appropriately deployed to meet the needs of the current service users. The recruitment practices safeguard service users. EVIDENCE: An examination of the rota for a three-week period and a discussion with staff indicated that in general staff are appropriately deployed to meet the needs of the current service users. At the last inspection, staff reported that the behaviour that can be displayed by a service user was having an impact on the staffing arrangements. At this inspection staff reported similar concerns. Staff were concerned that service users were not always getting the opportunity to go out due to having to ensure that there is sufficient staff to support a service user when they are displaying challenging behaviour. Following the last inspection the manager has kept CSCI informed of the action taken to address this situation. Additional staffing has been put in place when possible. Records showed ongoing efforts to secure additional funding from the placing authority to provide extra staffing on a more permanent basis. Following the inspection the manager reported that additional staffing has now been made available in the short term. A more permanent solution to the staffing Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 22 arrangements to support the service users at the home is needed. There is a core staff team employed at the home. There are currently no staff vacancies. Bank staff are used to cover absences. Bank staff have been recruited to work for Wirral Autistic Society to cover absences in the homes if needed or to provide support within the day care service. Wirral Autistic Society provides specialist services for people with autism and is accredited by the National Autistic Society. The prospectus and statement of purpose outlines how the specialist needs of service users will be met. A comprehensive induction and foundation training programme is provided to staff. This includes training around meeting the needs of individuals who have autism. Staff are encouraged to undertake an NVQ in caring for adults with a learning disability. At present 4 out of 14 staff hold a relevant NVQ. Further staff are undertaking this training in order to ensure that at least 50 of staff hold this qualification. Specialist training is provided to staff to assist them to support service users as appropriate. Appropriate support and training is provided in the induction of new staff. A new member of staff was interviewed and reported that they have been well supported and provided with induction training that has fully equipped them to work at the home. The records of recruitment for two members of staff were seen. The recruitment records contained all the required information and were well maintained. There was evidence to indicate that the staff are physically and mentally fit to work at the home. Giles Shirley Hall DS0000028492.V314559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including visiting the service. The welfare of service users is supported by the quality assurance systems in operation and by the systems in place to promote health and safety. EVIDENCE: The manager of the home has had several years experience of management in a care setting. The manager has appropriate qualifications in care and management and has undertaken periodic training to maintain and update her knowledge skills and competence. There are a range of quality assurance systems in place. Wirral Autistic Society is accredited by the National Autistic Society which carries out an inspection of services provided. Wirral Autistic Society conducts an internal audit of the society as a whole on an annual basis. The views of service users are obtained by key workers and the manager. The day service also provides a forum for service users to give their views on the services provided there. Questionnaires are sent to parents/carers and the manager reported that Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 24 Wirral Autistic Society is looking into sending questionnaires to other stakeholders. At present the manager reported that the views of stakeholders are obtained on an informal basis. Visits to the home by the representative of the registered provider are made on a monthly basis and a copy of this report is sent to CSCI. Training records and a discussion with staff indicated that training around safe working practices such as manual handling, infection control and first aid is made available to staff as part of their induction and updated accordingly. There is a rolling programme of training opportunities provided and staff can access this when required. There are a range of policies and procedures available that promote safe working practices. Wirral Autistic Society has a health and safety advisor who is available to provide advice and who has responsibilty for promoting a safe environment within the homes. At this inspection the records relating to safety checks of the home were available. The records relating to the checks of the gas safety, electrical wiring, and contractors checks of the fire equipment were seen and were in order. The records of fire equipment checks indicated that the fire alarm and emergency lighting are tested at appropriate intervals and that fire drills take place on a regular basis. A record had been made of fire safety training provided to night staff. At the last inspection a risk assessment indicated that both staff and service users were finding a fire door difficult to open due to the system of securing the door. Following the last inspection the manager reported that this had been attended to. There are new guidelines in place for locking the door and the manager reported that staff and service users are now confident about opening the door in the event of an emergency. The manager is keeping this new arrangement under review. Giles Shirley Hall DS0000028492.V314559.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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 17 Requirement The registered person must ensure that the records of food provided for service users contain sufficient information to demonstrate that their diet is satisfactory in relation to nutrition. The registered person must ensure that risk assessments around service users going out without staff support clearly indicate how this decision was reached and the safeguards in place to support the service user. The registered persons must ensure that a record is made of the action taken to investigate a complaint. The registered persons must ensure that all parts of the home are kept clean. Timescale for action 23/11/06 2. YA9 13 23/11/06 3. YA22 22 23/11/06 4. YA30 23 23/11/06 Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 27 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 YA30 Good Practice Recommendations It is recommended that steps are taken to identify a system for ensuring that the communal carpets are kept clean at all times. 50 of care staff are to hold an NVQ qualification or equivalent. 2. YA32 Giles Shirley Hall DS0000028492.V314559.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Giles Shirley Hall DS0000028492.V314559.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!