Inspection on 28/12/06 for 428-430 Gillott Road

This inspection was carried out on 28th December 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

428-430 Gillott Road 23/02/06

428-430 Gillott Road 28/09/05

428-430 Gillott Road 10/01/05

428-430 Gillott Road 08/09/04

428-430 Gillott Road 09/12/03

428-430 Gillott Road 26/08/03

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Tanglewood

88 Church Lane

Harmony Care Home

Olivet Christadelphian Care Homes

Sayer House

Beacon Centre For The Blind

60 Olive Lane

Bryndale Avenue, 41 Flats 13, 14 & 18

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

CARE HOME ADULTS 18-65 Gillott Road, 428/430 Edgbaston Birmingham West Midlands B16 9LP Lead Inspector Peter Dawson Key Unannounced Inspection 28th December 2006 09:30 Gillott Road, 428/430 DS0000016714.V319488.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 Gillott Road, 428/430 DS0000016714.V319488.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. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gillott Road, 428/430 Address Edgbaston Birmingham West Midlands B16 9LP 0121 454 9293 0121 455 8256 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Ms Deborah Holt Care Home 8 Category(ies) of Learning disability (8), Sensory impairment (8) registration, with number of places Gillott Road, 428/430 DS0000016714.V319488.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 23rd February 2006 Brief Description of the Service: 428-430 Gillott Road is registered to provide personal care and support to 8 adults with a visual impairment/ learning disability, who have been assessed as requiring full assistance with daily living tasks. The premises are divided into two homes, each with its own team of staff. Each has its own front door but is also internally interlinked. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. A number of adaptations have taken place within the home in order to meet the assessed needs of the service users. Service users are encouraged and supported to maintain links with their families and the local community. The home is situated in Edgbaston, a residential area of Birmingham and has ready access to local amenities. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on one day by the inspector from 10 a.m. – 5.30 pm. A completed Pre-inspection Questionnaire was returned to CSCI prior to the inspection by the service and provides a basis for information in this report. Three relatives and one social worker also provided written feedback. There was an inspection of the whole of the environment. All residents were seen and care practices, interactions and communication with staff observed, although residents were unable to give a view of the home due to communication limitations. Records in relation to the inspection process were accessed in the home. The home comprises 2 adjoining houses No’s 428 & 430 Gillott Road. They are run and staffed separately but have internal access at ground and first floor level. Two Managers run the home one is the Registered Manager both have management experience and qualifications. They share an office on the ground floor. The home provides care to some residents with behaviour that challenges the service. The comments from two relatives summarise the standard of the service. “ My son does have behavioural problems, care staff handle the situations very sympathetically when they arise. They also provide a loving and understanding environment sometimes in difficult circumstances. Certainly they try to provide the opportunities for their clients to make the most of their lives despite their disabilities”. Another relative commented “ I am always very happy with the care and support given to my son who is deaf/blind and can be very challenging at times. The staff are always incredibly kind, caring and look after him very well”. A placement social worker commented favourably about working closely in partnership with the home. Dependency levels are high in this home. Some have challenging behaviours. Five people have no sight, two have limited vision. Two have no hearing and two a hearing impairment. All have limitations in verbal communication but all are given opportunities to express themselves in non-verbal ways. The inspection indicated that a quality service with high level care and support was provided for the residents of this home who have diverse and complex needs. The weekly charges for care at Gillott Road are £1496 to £2593. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Considerable progress has been made in this home since the last inspection. The 13 requirements of the last report have been satisfactorily addressed. Staff have worked hard to improve the care planning, and health care record system and risk assessments now clearly record the level of risk. Protocols for PRN (as required) medication are in place and regularly reviewed. Some shortfalls in staff training have been resolved and all have received required statutory training including training specific to physical interventions. There has been considerable redecoration in the communal areas and bedroom areas. New furniture has been purchased for the two lounge areas and improved the comfort and presentation. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 7 A new en-suite facility has been provided for a resident on the ground floor whose personal care needs are now met. Criminal Records Bureau checks are now in place for all staff. Supervision is provided for all staff on a planned bi-monthly basis Testing of fire alarms and equipment is now carried out at required intervals. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Gillott Road, 428/430 DS0000016714.V319488.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 Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available to inform residents of the service provided. Pre-admission procedures and known and documented. EVIDENCE: The home has the Service users guide on CD Rom suitable for the needs of residents. Additionally the Guide is now in pictorial form and available to all residents. . There have been no new admissions to the home since the last inspection. One resident did leave recently and there is currently a vacancy. The Manager has considerable experience in pre-admission procedures which are supported by Sense organisation procedures. Gillott Road, 428/430 DS0000016714.V319488.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): Standards 6 – 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are to a high standard and contain all required comprehensive information. Risk assessments have been improved with the recording of levels of risk. Some very positive work has been done in this area. EVIDENCE: Care plans have been previously satisfactory and further improvements made since the last inspection. Care planning information is comprehensive and considerable. Accessing relevant information in care plans has been improved by indexing the information with sub-headings allowing swift and easy reference. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 11 Samples of care plans seen gave detailed information concerning all aspects of need. These included: Lifestory (social history), motivation, food, physical contact, communication guidelines (signs, gestures, objects of reference), best/worse days, parental contact, likes/dislikes, clothing, personal goals, routines and aspirations. The information was informative and to a high standard. Daily notes were similarly comprehensive. Detailed information provided by each staff shift. A detailed account of care and activities for each day (and night) were recorded. Additionally there was an information booklet summarising the care needs and personal profiles for each person including night care routines and needs. This information is for easy reference by Agency or Casual staff who may be employed. Risk assessments were in place and following a requirement of the last report now show the level of risk for each assessment. Risk assessments are crossreference with care plans and include all aspects of resident activity inside and outside the home. There are regular review meetings arranged by the home on a 6 monthly basis. Social Workers are invited and also parents who attend from various parts of the country. Residents are involved in and make decisions about their daily lives. Choices were seen to be made about breakfast. One resident prepared his own cereal, toast and hot drink, then washed his dishes, this is his preferred daily routine. There is encouragement to go out during the day. There are tactile objects of reference on boards in the hallway for individual residents indicating options available for the day - e.g. seat-belt clasp indicates external visit in mini-bus – residents went to the boards and their responses were clear to staff. One resident with quite unpredictable behaviour uses this and if he proceeds to put on his shoes the signs are positive, although not necessarily the final outcome. Staff show encouragement and sensitivity in this area. Gillott Road, 428/430 DS0000016714.V319488.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): Standards 11 - 16 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is positive evidence of opportunities for personal development and access to community and leisure facilities in an imaginative way. Family contacts are promoted and preserved. EVIDENCE: Some aspects of choice are outlined in the previous outcomes. All residents have their own “box” of tactile symbols which they readily use with staff. Some carry symbols with them when going out in a small bag around their waist an example would be sign for toilet need whilst travelling. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 13 Residents use the central facilities of Sense in the Birmingham area and a wide range of community facilities are also accessed. Residents are involved positively in ice skating, rock climbing, rambling, swimming/hydro-pool, art, woodwork, multi-sensory rooms, cinema, brine baths, pubs, cafes, restaurants, massage, shopping and IT. Staff spoke with enthusiasm out the skill levels of residents involved in activities such as ice-skating and rock climbing where they surprise parents, relatives, staff and instructors. These activities are clearly overseen by experience and qualified instructors with risk assessments in place but provide a sense of achievement and enjoyment for residents. All 7 current residents have family contacts of varying degrees. Several visit the home some visit parents. Some relatives live a distance from the home but visits/access facilitated by staff. One resident visits family in London and taken by staff with overnight stay in hotel prior to the contact. Another resident visits parent in South of England taken by staff twice each year for weekend stay. A resident was taken to Greece recently for holiday with his father who he had not seen for sometime and to meet his step-sister. The visit was extremely successful and re-established important contacts for the resident who also has an advocate (ex-member of staff). Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18 - 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal care is provided respecting the principles of care. Physical and emotional health care needs are met. Documentation is good. There is a safe system of medication in the home. EVIDENCE: Personal care support is required for many residents. This is clearly outlined in care plans and provided to ensure privacy and dignity. Records relating to health care needs were contained in individual health care folders and included diagnosed conditions, allergies, required support for medication and monitoring of health. There was a chronological record of interventions by health care professionals and outcomes were recorded. It was possible to monitor all aspects of health care need. Many residents have ongoing contacts with GP/Consultant although in one record inspected the last Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 15 health care check was June 2005. It is important that all residents have annual health checks with the GP. Health care records evidence input from specialist learning disability nurses, Speech & Lanugauge Therapist, Behavioural Specialists and Physiotherapist. Optical and audiology tests had been carried out and recorded. A resident with deteriorating physical condition has been assessed by a Physiotherapist and daily exercises recommended are documented and carried out as stated. The person is also on soft-food diet, has been assessed by the Speech & Language specialist, has some food restrictions but is supervised at all times whilst eating due to choking risk. This is accurately recorded with specific instructions to staff. At the time of the last inspection regular daily tests relating to blood-sugar levels of a resident had not been accurately recorded. This situation has changed. The residents condition has stabilised and daily urine test secured by staff. There is also detailed dietary information and Clinical Nurse Specialist provided assessment and advice. One resident presents regular instances of challenging behaviour. All incidents are notified to CSCI and these were discussed in some detail during the inspection. The behaviour is mainly focussed on self-harm by the resident. All incidents are well documented and staff have all had training in the management of violence and aggression with specialist approved training in control and restraint (CPR) techniques. Diversionary tactics are used effectively to ensure the safety of the resident and reduce the risk of self harm or harm to others. Staff are very experienced in this area and in the techniques used – the instances are often regular and unpredictable. Behavioural Specialists from the Learning Disability service are involved in trying to establish patterns and triggers for the behaviours. A new Consultant Psychiatrist has taken a fresh look at the needs of this resident and been particularly helpful in reviewing medication and extending the diagnosis. A schedule of therapeutic activities including massage, hydro-pool therapy and visits to brine baths have proved helpful in the management of this person. Clearer guidelines were required at the time of the last inspection relating to health monitoring records and risks of constipation in relation to a resident. These have been adequately addressed with a protocol in place for the latter. The medication system was inspected and records seen had been accurately and adequately completed. There were no gaps in medication administration records. New protocols have been established/reviewed in relation to PRN (as required) medication. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures in place to protect residents from abuse – these have been tested and found to be adequate. Attempts are made to provide residents with an understanding of the complaints procedures. Staff are vigilant about any changes in behaviour of residents which may indicate concerns. EVIDENCE: There is a CD/picture format for residents outlining the complaints procedures. All residents have family contacts/visits, one has an advocate - providing opportunities for residents to express concerns or complaints. There is not a copy of the complaints procedure in the home for visitors and this should be provided. The procedures for reporting complaints and staff reporting incidents has been tested in the recent past and resulted in investigations and action under Vulnerable Adults procedures. Appropriate action as taken by the providers to safeguard residents. A previous requirement to provide CRB checks for all staff has been met. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 17 Physical intervention is required on occasions as a last resort. This applies to one resident. Staff have all had approved and appropriate training and annual refresher training also provided in this area of work. Incidents of challenging behaviour are frequent but all were seen to be documented adequately with the required details. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 – 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Considerable work has been done to improve the decoration and furnishing of the home. It is now homely, comfortable and resembles a domestic environment. Immediate action must be taken to lock and secure the door to the cellar area. EVIDENCE: Since the last inspection 3 requirements relating to the environment have been met: A new en-suite shower room has been created in the ground floor bedroom to meet the changed needs of a resident. This provides an excellent facility for him. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 19 Walls have been painted in the walk-in shower room. A requirement to provide a wash-hand basin in a bedroom has been considered and discussed with other professionals. The resident would reject/not use a wash-hand basin and therefore it has not been provided. There are in fact 2 bedrooms without wash-hand basins. In one bedroom the resident would not tolerate one. He refuses to have a wardrobe or drawers and insists upon his clothes being neatly spread on the floor area. He also refuses to have other furniture or chairs in the room. The room has been redecorated and quite presentable although stark. He is happy with the facilities he demands and has. In another bedroom of a resident with challenging behaviours a wash-hand basin had to be removed for safety reasons. The person has a propensity for self harm with head-banging –the walls have been fitted with carpeting to reduce the risks of injury. This resident demands a room of low temperature and to accommodate this the room has been fitted with air-conditioning. The room has also been redecorated and presents well. These residents will not tolerate pictures/photographs on the walls. In contrast another bedroom is well personalised and furnished with a settee for self and visitors with TV etc. The room also has en-suite facilities, has been recently re-carpeted and redecorated. There has been considerable redecoration throughout the home which presents as a homely, domestic environment with good standard furnishings and equipment. In both areas of this home No’s 428 and 430 Gillott Road new lounge furniture has been provided with sofas and armchairs and both lounge areas redecorated. All outstanding environmental issues mentioned in previous reports and Regulation 26 visits have been quite adequately addressed – there are no outstanding issues. The Manager reports a good and immediate response from the owners of the property (Beth Johnson Housing Association) and the Sense organisation. The door to the cellar which houses the boiler was found to be unlocked and the key not in the usual position above the door. This door should be kept locked at all times and the Manager undertook to provide immediate security for the door pending location of the key. A duplicate must also be kept in a secure place as an alternative. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 – 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A well motivated, committed, competent and well-trained staff group was evidenced at this inspection. Recruitment policies/procedures protect residents. Staff are well supported and supervised. EVIDENCE: There appears to be a particularly well-motivated staff group in this home. Discussions with staff were open, positive and relaxed. Staff and residents were clearly relaxed in each others company. Staff talked to and smiled at residents encouraging them with respectful humour and gestures. Staff skills were evident throughout observations during the inspection. Additional staffing hours are provided 1:1 with two residents and the positive engagement in encouraging, enabling and diverting certain residents was very evident and impressive. The skills of all staff were tested but successful in the operation to prepare and take a group of residents out in the mini-bus for a walk and meal. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 21 A total of 700 staffing hours are provided in total in the home - 422 hours at No 428 and 280 hours at No 430 (lower dependency). These figures include additional 1:1 hours for 2 residents, 119 hours and 52.5 hours respectively. The Manager was concerned to ensure that the staffing hours complied with the computation of the Department of Health Guidelines. This was discussed in detail and she was re-assured that the total number of hours exceeded the computation for the required minimum number of staffing hours. Three requirements of the last report in relation to staffing have been met. The number of agency staffing hours has been reduced with the appointment of additional casual staff providing continuity. Criminal Records Bureau checks have now been obtained for all staff and staff now receive regular supervision at least 6 times per year as recommended (records seen). The recommended minimum 50 of NVQ trained staff is exceeded. Further training is currently taking place. The staffing matrix seen confirmed all statutory and required training had taken place. Staff meetings are held monthly and minutes seen showed good attendance and the opportunity to raise any areas of concern. The staffing hours had been questioned in feedback from a relative but the levels are adequate and the resident has additional 1:1 hours allocated. Recruitment procedures were inspected. All required checks, references and documentation had been provided for new staff prior to employment. Induction training had been provided in all statutory and other training areas. Prior to interview inexperienced prospective carers are invited into the home for a day and involved in role play and written projects. If satisfactory they are invited to interview. Training records showed that SENSE has a good rolling programme of training and some gaps identified at the last inspection have been actioned. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37 and 39 - 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed. The rights, interests, health and safety of residents are promoted by a competent staff team. EVIDENCE: This home comprises No’s 428 & 430 Gillott Road each accommodates 4 residents, but there is access internally between the adjoining houses. The units are run and staffed separately although they are registered as one unit. There are in fact 2 Managers, one is approved as the Registered Manager. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 23 Both managers now share an office on the ground floor and allows direct involvement and management in the daily running of the home. Both Managers have NVQ4 in Management and the Registered Manager has the Registered Managers Award (RMA). The home is well run and managed. Staff are highly motivated, imaginative and committed to resident care. There were many examples of this seen throughout the day of the inspection. There is an open and inclusive atmosphere between Managers, staff and residents. Previous requirements have been made in the absence of regular checks of fire equipment. On this visit records showed that weekly checks of the alarm system and emergency lighting had taken place. There had been regular fire drills involving residents also. The fire risk assessment was in place but required updating. The Manager intends to complete this soon. The home were advised to provide individual fire evacuation plans for all residents. There are high and diverse dependency levels in the home and these should be included in the plans. Hot water controls are provided on all outlets in resident areas. There is also a manual weekly check and recording of temperatures. All required notifications to CSCI have been provided under regulation 37 and this included the many instances of challenging behaviour. Regular Regulation 26 visits had been carried out and reports sent to CSCI. Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 X 3 3 3 2 x Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 Standard YA19 YA22 YA24 YA42 YA42 Regulation 12(1)(a) 22 13(4)(a) 23(4) 23(4) Requirement Annual health checks must be arranged for all residents. Provide copy of complaints procedure in the home for visitors. Door to cellar must be locked immediately to ensure safety of residents. Update fire risk assessment Provide individual fire evacuation plans for each resident. Timescale for action 28/02/07 31/01/07 29/12/06 31/01/07 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gillott Road, 428/430 DS0000016714.V319488.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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