Inspection on 26/03/08 for 115 Gough Road

This inspection was carried out on 26th March 2008.

CSCI found this care home to be providing an Adequate service.

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

115 Gough Road 26/01/07

115 Gough Road 29/11/05

115 Gough Road 05/07/05

115 Gough Road 29/11/04

115 Gough Road 06/05/04

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 Gough Road, 115 Edgbaston Birmingham West Midlands B15 2JG Lead Inspector Julie Preston Unannounced Inspection 26th March 2008 10:30 Gough Road, 115 DS0000016712.V358391.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 Gough Road, 115 DS0000016712.V358391.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. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gough Road, 115 Address Edgbaston Birmingham West Midlands B15 2JG 0121 446 6744 0121 446 6289 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 Miss Sarah Homer Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2007 Brief Description of the Service: 115 Gough Road is a large detached Victorian house situated in a quiet residential road in Edgbaston. Public transport is close by and the home is approximately two miles from the city centre of Birmingham. Gough Road currently accommodates five men. The accommodation is spacious and includes a large reception hall, lounge, dining room, kitchen, office/meeting room, laundry and a ground floor bedroom with ensuite facilities. Four further bedrooms, (one of which is ensuite), two bathrooms and a toilet are situated on the first floor. The home has a second floor, which is inaccessible to people who live there, and provides a storage area and a staff sleeping in room. The garden has been developed so that the top area includes a large patio area which is accessible to people and contains garden furniture and a range of plants. The lower part of the garden is extensive and cannot be used as it is overgrown and unsafe. This area is securely contained so that people are not placed at risk of possible harm. The home provides care and support services to five adults with learning disabilities and a sensory impairment. The fees charged each week currently range from £1620.82 - £3142.36. People make a contribution to this fee from their welfare benefit. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The purpose of the visit is to ensure that the care and practices in this service are safe and protect the people who live there from potential and actual harm. We also look at the experience of the people living there, we do this through ‘case tracking’ which involves meeting the person, checking that the care they receive is needed and that the person is happy with the care and attitude of the staff. We also look at records related to medication management, safety of equipment and records of activities to ensure that practices and procedures in the service are safe. Discussion is undertaken with managers and staff in the home to find out how they view the service and their understanding of the needs of those who live there. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. Staff files and health and safety records were reviewed. We looked around the building to make sure that it was warm, clean and comfortable. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. The staff team know people who live in the home well and have learned skills to communicate with them effectively. This helps them understand people’s needs. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 6 The home is good at supporting people to keep in touch with their friends and relatives so that they maintain relationships that are important to them. People get the food they need and like to help them stay healthy and well. Records that explain how to care for people are well written so that people are cared for in a way they like and need. The home is making sure that vulnerable people are well protected from possible harm to keep them safe. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 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. Gough Road, 115 DS0000016712.V358391.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 Gough Road, 115 DS0000016712.V358391.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: The home has a statement of purpose and service user guide, which is made available to people who live there and their relatives. We were told that Sense (the registered providers) makes the service user guide available in different formats such as Braille and audio tape, to make the document more accessible to people who live in the home. There have been no new admissions since the last inspection and there are currently no vacancies. There are systems in place to ensure that individuals’ needs are assessed before they move into the home and that people have an opportunity to visit and stay over prior to making any decisions about whether to move in. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 9 Referrals from people who may wish to live at Gough Road are received by a Referrals and Information officer based at Sense’s regional office. There is a national policy for referrals, which is followed to assess that people’s needs can be met by the home prior to admission. This should assist people to feel confident that the home they choose is suitable for them. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems of care planning and risk assessment, which staff understand so that people’s needs are consistently met. People who live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: The home has a Practice Development Worker (PDW) who works to support the staff team with the development of peoples’ care plans and risk assessments. The care plans for two people were sampled. Both contained information about how staff should support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. The records sampled showed that monthly meetings had been held to review care plans and risk assessments so that it was clear they remained relevant to people’s individual needs. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 11 It was positive to note that the PDW had identified areas for improvement, which had been followed up by the staff team. For example, food records for one person had not been completed on a regular basis. The PDW raised this at the person’s monthly meeting and from looking at records after that date significant improvement had been made. Some of the care plans had not been dated and it is recommended that this be done to aid the process of review and to continue to ensure that plans remain relevant to people’s current needs. People who live at Gough Road have specific needs with regard to communication. The care plans sampled were detailed and explained clearly how staff should support the person to make decisions and choices by use of objects and sign language and how to understand the person’s expressive communication skills. We spoke to a member of staff, who described a range of techniques used by the team to assist their understanding of people’s communication so that their choices are respected. This was consistent with the care plans sampled. The member of staff had been employed for only a short period of time and it was evident that they had received good information upon which to support people who live in the home. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. Risk assessments sampled had been reviewed on a regular basis. Gough Road, 115 DS0000016712.V358391.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: Each person has a weekly activity schedule that has been developed according to their preferred activities and routines. The activity plans were seen to vary from week to week so that people have opportunities to do different things that they like. Daily records were sampled to check that people had regular opportunities to take part in things they enjoy doing. Records showed that people undertake many activities such as swimming, ice skating, rock climbing, shopping, eating out, cooking, sculpting and visits to local places of interest. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 13 Each activity had a corresponding risk assessment so that people could take part safely, which included details of how they prefer to be guided and a plan to communicate to each person what is going to happen during the activity. There was evidence that people take part in domestic skills so that they develop and maintain independence in their day-to-day lives. For example, time is planned for people to shop for and cook a snack or dessert of their choice. Records are kept which describe people’s responses to activities, which staff confirmed aided future planning. The daily routines within the home were observed to promote people’s privacy and independence. Staff responded quickly to people who communicated clearly that they wished to change activity or make a drink/food. Each person has a doorbell outside their bedroom door, which staff use before entering the room. Staff wear individual identity bracelets to help people recognise who is in their home. The home has a sensory room, which is equipped with light panels, vibro seating, musical instruments, a stereo system and textured walls. The room was well used during this visit and staff confirmed that people spend time relaxing in there. From observation of care plans, menus and from discussion with staff it was evident that people’s cultural needs were understood and planned for. Festivals such as Christmas and Eid are celebrated and people had recently been involved in making and decorating eggs for Easter. Separate fridges and freezers are available for the storage of Halal products and staff demonstrated knowledge of foods that are Halal (can be eaten) and those that are Haram (can’t be eaten). It was noted that there are no specific cooking utensils and chopping boards for the preparation of Halal foods. Staff did state that they always prepared Halal and Haram foods separately however, it is recommended that the equipment be provided to reduce any risk of food contamination. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts, Halal and soft consistency meals, which is reflective of people’s cultural and healthcare needs. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about peoples’ relatives birthdays, so that cards and presents could be sent. The home has a visitor’s policy and the person in charge commented that relatives have regular contact either by telephone or in person. Sense has a family liaison officer whose role is to support and advise families or to advocate for people who have no input from relatives. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 14 Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to meet peoples’ personal and health care needs. Medicines management is not always robust, which could lead to peoples’ needs not being met. EVIDENCE: Two personal and health care plans were sampled at this visit. From observation of records and discussion with staff that work in the home, it was clear that daily routines are flexible and that people have a choice about when they eat, get up and go to bed. The records sampled for people “case tracked” showed that their personal care routines had been planned so that each person used their skills as much as possible to maintain their independence. For example, staff talked about the importance of prompting people to wash with minimum support and the use of objects of reference to enable people to understand their routines. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 16 Each person has a Health Action Plan (a document that explains what a person needs to do to stay healthy and the health care services they need to access to do so). The plans sampled described the person’s needs and how they communicate pain so that staff can identify if a person is unwell. People who live at the home have a range of healthcare needs and sampled records showed that they maintain regular contact with healthcare professionals. The outcomes of appointments had been clearly recorded so that staff had up to date information about each person’s health. In two people’s cases it was not clear from discussion with staff on duty or from the healthcare records how often chiropody treatment should be offered. The records showed that prior to December 2007, treatment had been regular but none had been received after that date. This must be clarified so that people receive services that are reflective of their healthcare needs. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medicines were stored in a locked cabinet for security. Where people are prescribed medication on an “as required” basis, written protocols were in place to guide staff as to when they should be given. In one case paracetamol had been signed for as being given to a person, however there was no information on the medication record about the number of tablets administered and no information about the number of tablets that had been received into the home so that accurate auditing could take place. On seven occasions in March 2008, powder products and oral sprays had not been signed for as administered to one person and a dosage of saline solution not signed for as administered to another person. These issues need to be addressed so that people receive their medication safely and to maintain their health. Medicines that are blister packaged and the corresponding administration records were sampled. There were no anomalies, which indicates that the medicines had been given as prescribed. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: There have been no complaints made about the home since the last inspection. A log of complaints is maintained that records the nature of the complaint and the action taken in response. This was available for inspection. Information received before this visit on the Annual Quality Assurance Assessment stated that SENSE has a Complaints free telephone line, which can be accessed by anyone, 24 hours a day. Information about the complaints procedure is made available to families and friends in the statement of purpose and service user guide. A member of staff confirmed that this was necessary as people who live in the home would be unable to raise concerns without assistance. Some people who live in the home demonstrate behaviour that is challenging. Guidelines to manage such behaviour were seen to be in place and reviewed on a regular basis so that it could be determined they remain relevant to people’s assessed needs. Two members of staff explained that there is input from the Behaviour Management Support team to assist in reviewing Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 18 guidelines. Both staff members were able to explain their role in supporting people to reduce any known anxiety and had clearly read and understood the guidelines in place. This should enable people who live in the home to receive consistent care from the staff team. Staff have completed training in the protection of vulnerable adults and the management of challenging behaviour and Non-violent Physical Crisis Intervention training, which should enable them to safeguard people who live in the home. An up to date inventory of peoples’ belongings is maintained so that staff can keep track if anything goes missing and look after peoples’ possessions. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s cleaning routines do not always provide a healthy and safe environment for people to live in. The planned refurbishment of areas in the home will offer people a more pleasant place to live. EVIDENCE: Gough Road is situated in a residential area approximately two miles from Birmingham City Centre. There are local amenities such as shops, cafes and restaurants nearby, which is important to the people who live there as they enjoy using these facilities. A tour of the premises was undertaken and several areas that need to be improved were noted. The kitchen cupboards and their contents, walls and skirting boards were dirty and stained which indicates that cleaning routines are not sufficient to maintain a hygienic environment. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 20 A bathroom on the first floor had some damage to the plasterwork and the dining room walls were also damaged, which did not look pleasant. Bedrooms are located on both the ground and first floors of the home and are all of a good size so that people have space for their personal belongings. All bedrooms are due to have some refurbishment to make minor repairs. It was confirmed at this visit that the landlords of the building, Moseley and District Housing Association, have planned a programme of refurbishment to improve the environment. A list of tasks to be completed, which included work to the kitchen was seen to support this. Shared space consists of a lounge, separate dining room and sensory room, all of which are located on the ground floor. The building is spacious and is due to be redecorated so that door frames and handrails are painted in contrasting colours to assist people with a visual impairment to move more freely around their home. Objects of reference are situated in key places, such as on doorways to help people locate rooms and equipment. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates a robust system of recruiting staff for the protection of the people who live there. People are supported by a well-trained and competent team of staff who have good understanding of their individual needs. EVIDENCE: We observed staff working with people who live in the home and considered their interaction to be both friendly and respectful. People who were unable to verbally communicate an opinion about the staff team were noted to seek them out during this visit and appeared very comfortable in their presence. We spoke to staff during the visit and found them to be knowledgeable about people’s needs. One staff member said, “the care plans and other staff have helped me get to know X”. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 22 The staff rota sampled showed that some male staff are employed, which is consistent with the gender of the resident group and that there are sufficient staff are on duty each day to meet peoples’ needs. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. The checking of staff files showed that staff receive formal supervision at regular intervals to offer them the support they need to carry out their work and to receive feedback on their performance. One newly employed member of staff confirmed that she had received an induction to working in the home and that this had helped her understand people’s needs and how to care for them effectively. To ensure that people are supported by a qualified staff team at least 50 of staff should achieve a National Vocational Qualification (NVQ) in care. Information provided by the home’s manager within the Annual Quality Assurance Assessment (AQAA) stated that 70 of the staff team had achieved or were working towards this qualification. The registered provider (SENSE) offers a rolling programme of staff training so that staff have regular opportunities to complete both mandatory sessions and that which is relevant to people’s assessed needs such as communication awareness and working with deaf/blind people. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 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 managed and peoples’ health and safety is promoted and protected. EVIDENCE: The home has a registered manager who has been in post since 2007. There is also a deputy manager, who was present at this visit. It was reported in the AQAA that the manager is working towards her NVQ Level 4 and registered manager award, which she hopes to complete in the next twelve months. Quality assurance systems are in place. A representative of the registered provider visits the home on a regular basis to report on the standard of care provided of which reports are made available to the home and CSCI. We were Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 24 told that the manager attends two reviews of the quality assurance systems in place each year so that systems can be audited for effectiveness. Records sampled showed that other quality assurance audits are in place such as the regular reviewing of care plans and risk assessments. A number of checks are made by staff to make sure that peoples’ health and safety is maintained and some of these were sampled. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. The home’s rota showed that staff who lead each shift have responsibility for checking hot water temperatures to make sure they do not pose a scalding risk and checking fridge and freezer temperatures to ensure that food is stored safely. Records were seen to evidence that these tests had been completed on a regular basis. People who live in the home do not have a plan or risk assessment that describes how they should be supported to leave the premises in the event of a fire or the fire alarm being activated. A member of staff commented that they were not aware of the procedure for evacuation at night despite having undertaken a sleep in duty some weeks ago. It was noted that the lift from the patio area to the lower garden did not work. Access is therefore down a set of steps, which are secured by a gate. It was not evident that the lift would be repaired and the person in charge told us that risk assessments were due for each person so that they could access the garden safely. The risk assessments had not been completed at this visit. Observation of the staff training matrix showed that the majority of staff had undertaken training in health and safety, infection control, first aid and fire safety which should promote the health and well being of people living in the home. Gough Road, 115 DS0000016712.V358391.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 4 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Gough Road, 115 DS0000016712.V358391.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 YA19 Regulation 17(1)(a) Requirement Health care plans must specify the frequency of appointments with health care specialists so that people can be confident that they will receive treatment according to their individual needs. Medicines received into the home must be entered onto the medication record so that effective auditing can take place for the ongoing protection of people who live there. People must receive their medication as prescribed and administration recorded so that it can be clearly demonstrated that the person has received their medication. The home must be kept clean so that people live in a hygienic and safe environment. There must be arrangements in place to move people safely from the building in the event that the fire alarm is activated. Timescale for action 30/05/08 2 YA20 13(2) 30/05/08 3 YA20 13(2) 30/05/08 4 5 YA30 YA42 23(2)(d) 23(4)(c) 30/05/08 30/05/08 Gough Road, 115 DS0000016712.V358391.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 2 3 Refer to Standard YA6 YA17 YA42 Good Practice Recommendations Records relating to people’s care should be dated and signed so that it is evident they are relevant to the person’s current needs and to aid the process of review. Chopping boards and cooking utensils should be provided for use specifically with Halal products to reduce the risk of food contamination. Risk assessments should be completed for each person living in the home with regard to access from the patio to the lower garden so that their health and safety is promoted and protected. Gough Road, 115 DS0000016712.V358391.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Gough Road, 115 DS0000016712.V358391.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. 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