Inspection on 29/08/07 for 22 Hallewell Road

This inspection was carried out on 29th August 2007.

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

Other inspections for this house

22 Hallewell Road 20/11/06

22 Hallewell Road 24/01/06

22 Hallewell Road 06/06/05

22 Hallewell Road 22/11/04

22 Hallewell Road 02/06/04

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 Hallewell Road, 22 Edgbaston Birmingham West Midlands B16 0LR Lead Inspector Gerard Hammond Key Unannounced Inspection 29th August 2007 09:30 Hallewell Road, 22 DS0000017074.V343561.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 Hallewell Road, 22 DS0000017074.V343561.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. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hallewell Road, 22 Address Edgbaston Birmingham West Midlands B16 0LR 0121 455 8269 0121 454 5177 martom01@blueyonder.co.uk 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) Mrs Marcella Marie Higgins Mrs Marcella Marie Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Residents must be aged under 65 years One named service user with additional physical disabilities may be resident at the home. One existing named person can be accommodated and cared for in this home for reason of mental health needs subject to appropriate review of the home’s suitability. The home can continue to accommodate two named service users who are over 65 years. Date of last inspection Brief Description of the Service: 22, Hallewell is a three-bedroom home for adults who have a learning difficulty. The home is a three storey building in a quiet residential road in Edgbaston, Birmingham. The home is within walking distance of shops, places of worship, a park, pubs, restaurants and a selection of bus routes providing access to the city centre. The registered premises comprises of two lounges, a kitchen with a dining area, WC, a separate laundry and a conservatory area. The three service users each have their own bedroom on the first floor. There is a bathroom and a separate toilet on the first floor. The registered person and her partner live on the premises on the third floor. The home is furnished and decorated to a high standard and is reflective of a family type domestic dwelling. To the rear of the home is a garden with lawned areas, a patio and at the top of the grounds there are three wooden buildings in the style of a western town to provide entertainment on the country and western theme for those who live and work at the home. The home is also used as a day facility for three people on most days of the week except Saturdays. Two people currently use this facility. The current range of fees is reported to be £627.02 - £648.97 per week. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information was gathered from a number of places in the course of completing this key inspection, which was unannounced. The Manager completed an Annual Quality Assurance Assessment prior to the inspection visit. Other documents, including previous inspection reports, personal files, care plans, staff files and safety records, were examined for the purposes of compiling this report. The Inspector was able to meet all of the residents, and to observe directly members of the staff team giving support. The Manager and two members of staff were interviewed, and a tour of the building was completed. Thanks are due to the residents, Manager and staff for their hospitality and cooperation throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Individual care plans could be better if they included people’s personal goals. These should be set so that it is possible to see whether or not they have been met and whether people are getting the right support to achieve the things that are important to them. Using person centred approaches could help to do this better. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 6 Records about people’s activities should be more detailed, so that it is clear that the things they get to do are the things they want to do, and are helping them meet their goals. Staff supervision should be more frequent; to ensure that people working in the home are getting the support they need to do their jobs well. Fire drills should take place at least every six months, to make sure that everyone knows what they have to do in the event of a fire in the home. 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. Hallewell Road, 22 DS0000017074.V343561.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 Hallewell Road, 22 DS0000017074.V343561.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, 3, 4 & 5 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 help people make judgements about whether or not this service is right for them. They have opportunities to test this out by visiting the house and meeting people so that they can make an informed decision. Their support needs are properly assessed; to make sure that they get the care they want. Residents have written contracts, so that everyone knows what the service should provide. EVIDENCE: There have been no new admissions since the time of the last inspection. Two of the current residents have lived in the home for thirteen years, and the other person has been there for ten years. The service’s Statement of Purpose and Users’ Guide were fully assessed at the last inspection and judged to be up to standard. These documents were seen during the inspection visit, contain all information required and are up to date. Discussions with the Manager showed that appropriate systems are in place for introducing new residents in the event of a vacancy arising. Opportunities to come and visit the home and to stay over would be provided, so that prospective residents could try out what the service has to offer. Sampling of people’s records showed that people’s support needs have been assessed and that current contracts are in place, as required. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be developed, so that they include people’s personal goals and it is possible to tell whether or not these are being met. Risk assessments are also in need of improvement, so that it is clear what action needs to be taken to keep people as safe as possible. People are helped to make choices and decisions about things that are important to them, to help them be as independent as possible. EVIDENCE: Personal records were sampled. Individuals’ care plans are to a standard format and provide staff with adequate guidance about how to meet people’s support needs, particularly in describing their daily routines. Care planning and management were discussed with the Manager. It is clear that the “extended family” model of care in operation in this home gives her and the staff team unique insights into how residents like to be supported; as a result of the amount of time they spend in each other’s company. Conversations with the Manager and staff demonstrated that they have good, detailed knowledge of the support needs of the people in their care, though this may not always be Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 10 reflected in the written care plans. It should be acknowledged however, that there is clear evidence that plans are very much works in progress, and the Manager demonstrated a positive attitude towards developing them further. It was recommended that plans should be expanded to include individuals’ personal goals. Goals should have outcomes that can be clearly measured, and these should be evaluated when the plan is reviewed. At present, a monthly evaluation sheet is completed, so as to keep each person’s plan up to date and “live”. This is a good idea in itself, but in its present form the evaluation is little more than a tick list, and it is difficult to see what is being evaluated. It was suggested that setting specific goals would help this process to develop. For example, one person’s plan said that he likes to go to the local carvery for a meal. A measurable goal might be to ensure that he has the opportunity to do this once a month (or whatever interval is deemed appropriate and realistic). When the plan is evaluated, it should be possible to see whether or not this has been achieved within the timescale set, and so on. Goals to encourage people’s independence or develop their skills should set tasks to be achieved, so that a judgement can be made about whether or not the action taken to teach or encourage people to do things is actually working. It was further recommended that the use of person centred approaches would make a positive contribution to the development of care planning in the home, and help clarify some of the issues around setting appropriate goals. Throughout the course of the visit, staff were directly observed encouraging people to do as much for themselves as they are able. They were offered choices about activities, about making drinks and about what they wanted to eat. It was noted that it was difficult to make clear links between individuals’ risk assessments and their assessed needs and written care plans. For example, one person has restricted mobility, but there was no risk assessment about using the stair lift, or accessing the car or a taxi. This was discussed with the Manager. Risk assessments should include clear identification of potential hazards and make statements about the likelihood of these occurring. Control measures should then be devised to minimise or eradicate the possibility of hazards actually occurring, and these should be used to inform individuals’ care plans. Conversations with the Manager again provided evidence that issues had generally been considered appropriately, and actual practice generally provided adequate safeguards from identified hazards. Personal information is securely stored in the office. It was recommended that all information relating to named individuals should be maintained separately on their personal files, so as to comply with current data protection legislation. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People enjoy doing a range of things that they value and enjoy, and they are well supported to keep in touch with their families and friends. Recording of activities needs some improvement, so that it is possible to see how the things that people do are clearly linked to their assessed needs, and support them in achieving their personal goals. Residents have a varied and balanced diet and enjoy their food. EVIDENCE: As reported above, this home operates as an “extended family unit”, as the Registered Manager and her partner share their home with the residents living there. The service also provides day care to two other people, who come from a neighbouring residential home. All of the people using the residential and day service have an established, long-term relationship and appear to get on particularly well with one another. Routines in the house are very flexible, according to what people want. It was noted on arrival that some residents were just getting up, and enjoying the Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 12 relaxed pace of an easy morning. One of the residents attends a local day centre each weekday, and clearly values this highly. She has been going there for several years, and has significant relationships with the people she sees there during the week. Recent health problems have directly affected the attendance of the other two residents at the centres they were used to going to. The Manager is currently exploring other options, including local college and community settings, so as to provide people with an appropriate range of choices for the future. All of the residents said that they enjoyed the things they did, and that they were able to make choices about where they went and what they got up to. They said that they enjoyed each other’s company and were very happy living in their home. Personal records showed that people enjoy going to church, going dancing, visiting local pubs, theatres and restaurants. At home activities they like include knitting, playing dominoes, watching TV and doing quizzes. One member of staff has a particular brief to support residents undertaking activities of their choosing. The owners have a caravan at Brean, and residents enjoy going there when weather and their health allows. They also have a particular interest in “country and western” style music and dancing: they belong to a club and go to social events around the region, which the residents join in and say they enjoy. It was noted that activity recording is somewhat limited. This was discussed with the Manager: she said that the practice of recording in people’s daily diaries had lapsed, and she would start it up again. Activities should be purposeful: for example, the things people do might be to maintain or develop skills; activities might be therapeutic, or just for fun. A single activity (e.g. going for a walk to the shops) might be any of these things or even a combination of all of them. It was recommended that records should show clear links between what people do and their assessed needs and personal goals. Recording needs to be sufficiently detailed to support this. Residents are well supported to keep in touch with their families and people important to them. Conversations with the Manager showed that she goes to considerable lengths to ensure that this is the case, and residents confirmed this. The Manager holds clear views about the importance of good nutrition and is very knowledgeable about this. Particular efforts are made to source organically produced food, and the quality of the meals provided is high. People enjoy a wide range of recipes from around the world. Residents confirmed that they can have what they like, and they enjoy their food. One said “ I like the West Indian food” and another said, “I love the food here”. Food stocks were plentiful, and records provided additional evidence that residents have a balanced, varied and nutritious diet. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are well supported so that they get the care they need in the ways they like. Staff support residents to stay well and healthy. They make sure that people get the medicine they need in the right amount and at the right times. EVIDENCE: Staff were directly observed supporting residents. It is clear that they are all very comfortable in each other’s company and enjoy an excellent rapport. People’s personal grooming and attire provided evidence that they receive a very good standard of basic personal care. Individuals’ care plans include good detail of each person’s daily routines and how they prefer to be supported. Support was given in a warm and friendly manner and was appropriately respectful. Conversations with staff also provided evidence that they have good knowledge of the needs and wishes of the people in their care, developed over the substantial periods of time they have known each other. Residents confirmed that they like the staff, and that they get the help that they need. Records show that people’s healthcare is planned and monitored appropriately. Each person has a health action plan. Their weight is checked and recorded regularly, they have a nutrition screening assessment and they all have a Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 14 Waterlow pressure care assessment, which is kept under review. Personal notes show the involvement of members of the multi-disciplinary team including GP, Consultants, Physiotherapist, Psychiatrist, Chiropodist, Cardiologist, Community Nurses and Optician. A requirement made at the time of the last inspection that staff receive moving and handling training has now been met. No-one self-medicates. The home operates the Boots Monitored Dosage System (MDS) for administering medication. Individual records included a photograph and copies of current prescriptions. The Medication Administration Record (MAR) was examined and had been completed appropriately. The medication store was secure, clean and tidy. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. People know they can complain and are confident that their views are listened to and acted upon. They feel safe and are protected from abuse, neglect and self-harm. EVIDENCE: No complaints have been received in respect of this service since the time of the last inspection. The complaints policy and procedure were assessed at that time, and judged to be satisfactory. Conversations with residents confirmed that they know they have a right to complain, and that they know they can raise any concerns they have with the Manager. They all said that they would be comfortable doing this and believe that their concerns are listened to and taken seriously. They also know that, should they wish, they could get support from family members and others outside the home to make a complaint. Staff interviewed showed that they have an appropriate understanding of adult protection issues, and know what they have to do in the event of suspecting that abuse might have taken place. They have completed training in the protection of vulnerable adults from abuse. Appropriate policies and procedures are in place, including the local multi-agency guidelines. Residents said that they feel safe and secure in their home. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the benefit of living in a well-maintained house that is comfortable and homely, and meets their needs. The house is clean and good standards of hygiene maintained throughout. EVIDENCE: A tour of the building was completed. 22 Hallewell Road is a large terraced with accommodation on three floors. On the ground floor are two comfortable lounges. There is a large kitchen, which also doubles as the dining area. At the back of the house is the food store and office. There is also a toilet and newly installed shower room, recently adapted to meet the needs of one of the residents who has significant mobility problems. The residents’ bedrooms are all on the first floor, accessed by the main stairway or stair-lift. Rooms are all individual in style, reflecting the personality and character of the occupant. They are comfortably furnished and personal effects and possessions are very much in evidence. There is a separate bathroom and toilet on this floor also. The second floor is occupied by the Manager and her partner. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 17 At the rear of the property is a “courtyard patio” accessed through French windows in the rear lounge, or through the kitchen. Further back is additional garden space with more seating areas and wooden outbuildings reflecting the owner’s interest in western themed entertainment. These are used as summerhouses in the warmer weather. The house has a comfortable “lived in” feel about it: it is well decorated and maintained and provides all who live there with a homely and welcoming environment. The home is kept clean and tidy and a good standard of hygiene maintained throughout. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by a familiar, well-trained and motivated staff team, so the support they receive is consistent and dependable. EVIDENCE: As reported at the time of the last inspection, there have been no changes to the staff team since that date. The Manager and her partner live on the premises and state that they are available at all times. As reported above, the model of care in operation is that of an extended family. Two full time staff support the Manager and her partner in providing care and support to the residents, and there is additional support for day activities from another member of staff. The staff complement is considered sufficient to meet the residents’ assessed care needs. The staff work well together as a team and cover the full range of duties between them. They demonstrate a good knowledge of the needs of the people in their care and have a good rapport with them. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 19 Previous requirements with regard to staff receiving moving and handling and first aid training have now been met. Staff are trained to NVQ level 2 and above, meeting the required standard. It was noted that refresher training in food hygiene is now due. The Manager was able to demonstrate that she is taking active steps to make arrangements for this to take place, and is waiting for places to become available on the designated course. It was recommended that transferring all the information currently held on staff files to a spreadsheet or chart / table would simplify monitoring and management of training requirements. Evidence was seen that staff are receiving regular formal supervision, but this is not yet quite up to standard. Formal supervision should take place at least six times in any twelve-month period (pro rata for part-time staff), with written records of meetings held. It should be acknowledged that the small size of the home, consistency of the staff team and frequency of contact mean that issues are generally dealt with on a dayto-day basis, as they arise. Staff files were sampled, and contained all relevant documentation, as required. Individual members of staff were very positive about their roles within the home. One said, “I love my job”, and another said, “I love working here”. Feedback from relatives and other professionals about the support given to residents was similarly positive. One wrote, “I have been calling at this home for seven years, always finding staff and residents very happy and confident”. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the benefit of living in a home that is generally well run. They are confident that their views are fully taken into account, so as to develop the service as they would wish. People’s health safety and welfare are generally well protected. EVIDENCE: The Manager is appropriately qualified, holding NVQ level 4 and the Registered Managers’ Award. She has many years experience in social care, and in looking after this particular group of residents in particular. She demonstrates a high level of commitment to the people in her care, not least by sharing her home with them and supporting them as part of “an extended family”. Her management style is open and inclusive and she clearly commands the respect and affection of her staff team, who described her as “one in a million”. She is well supported by her partner who is actively involved in running the home. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 21 Residents were quite open that they felt they could speak to her about anything. Since the last inspection the Manager has purchased a new quality assurance and monitoring system. She is in the process of working through this, and was able to demonstrate the progress she has made to date during the inspection visit. This is supplemented by existing practice of directly seeking the views of residents, staff, relatives and professionals who have involvement with the home. Requirements were made at the last inspection with regard to arrangements for supporting evacuation of the residents in the event of a fire. These have now all been met. A key to the French doors giving access onto the flat roof at the rear of the property has now been put in place. A wheelchair for one resident who has mobility problems is now stored in his bedroom, and arrangements are now in place to ensure that the Manager and her partner now have access to a telephone on the second floor during the night. Safety records were sample checked. The fire alarm has been checked regularly, and a full record maintained. The system and fire-fighting equipment have been serviced. Gas appliances have been serviced, and portable appliance testing of electrical equipment has been carried out. The five-year electric circuit certificate was renewed last year. The stair lift has also been serviced as required. It was noted that the last recorded fire drill was in December 2006. It was reported that a drill had been carried out in June 2007, but that the record had not been completed in oversight. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 3 ENVIRONMENT Standard No Score 24 3 25 X 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 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 23(4) Requirement Ensure that fire evacuation practice takes place at least every six months, so that people know what they must do in the event of a fire. Keep a full written record. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations Develop individual care plans to include people’s goals, so that it is possible to see whether or not these have been met. Use person centred approaches so that this can be done effectively. Develop written risk assessments to ensure that hazards are correctly identified, a judgement made about the likelihood of occurrence, and control measures put in place to minimise risk effectively. Maintain all personal information about named individuals on their personal (separate) files, in order to comply with current data protection legislation. Transfer all staff training information to a spreadsheet or chart to make it easier to monitor and update training DS0000017074.V343561.R01.S.doc Version 5.2 Page 24 2. YA9 3. 4. YA10 YA35 Hallewell Road, 22 5. 6. 7. YA35 YA36 YA42 requirements. Arrange for staff to receive refresher training in food hygiene, so as to ensure safe practice. Arrange for staff to receive formal supervision at least six times a year, to make sure they get the support they need to do their jobs well. Ensure that fire drills take place at least every six months, so that everyone knows what they should do in the event of a fire in the home. Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 25 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 Hallewell Road, 22 DS0000017074.V343561.R01.S.doc Version 5.2 Page 26 - 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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