Inspection on 23/06/08 for Hampton Road, 20

This inspection was carried out on 23rd June 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hampton Road, 20 27/02/07

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Hampton Road, 20 Erdington Birmingham West Midlands B23 7JJ Lead Inspector Rebecca Harrison and Sue Woods Key Unannounced Inspection 23rd June 2008 10:00 Hampton Road, 20 DS0000068553.V366681.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 Hampton Road, 20 DS0000068553.V366681.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. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hampton Road, 20 Address Erdington Birmingham West Midlands B23 7JJ 0121 3776601 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) Coventry and Warwickshire Partnership Trust Miss Emma Louise Faulkner Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can provide care and accommodation for 4 service users under 65 for reasons of learning disability. That named service user over 65 years can be accommodated and cared for. 27th February 2007 Date of last inspection Brief Description of the Service: The registered provider changed in October 2006 from North Warwickshire NHS Trust to Coventry and Warwickshire Partnership Trust. Hampton Road is situated in a cul de sac in the Erdington area of Birmingham. The home provides care and accommodation to four adults aged between 18 and 65 years with a learning disability and additional needs including behaviours that can challenge. At the time of the fieldwork three people were living at the home and one person had commenced introductory visits. Shops, pubs, restaurants and places of worship are within walking distance. Public transport systems are also located close to the home. There are two bedrooms on the ground floor and a bathroom and separate shower room. There are two bedrooms on the first floor and a bathroom and separate toilet facility. There is a spacious lounge, dining room and kitchen. There is ramped access to the front of the home. Ground floor hallways and doorways are sufficiently wide to provide access to wheelchair users, however there is no passenger lift therefore the first floor is not accessible to people that cannot use stairs. The rear garden is spacious and has no level changes. Consultation with people who live at 20 Hampton Road takes the form of regular observations and detailed care and support plans that identify and review likes and dislikes. Advocacy services are promoted. Previous inspection reports are available in the hallway of the Home for people to read. Because a Service User Guide was not available at the time of the inspection we are not able to confirm the present fees charged by the Home, therefore the reader may wish to contact the Home directly for more information. Hampton Road, 20 DS0000068553.V366681.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 2 star. This means that people who use this service experience Good quality outcomes. The unannounced inspection of 20 Hampton Road took place on 23rd June 2008 at 10.00 am. Two inspectors carried out the inspection that lasted three and a half hours. Prior to the visit we contacted the home to identify when people would most likely be at home. The inspection reviewed all twenty two of the key standards for care homes for younger adults and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection we, the commission, met people who live at the home and spoke with the five staff on duty at the time of the visit. Prior to the visit we spoke over the phone with one staff member. We also met a student nurse who was currently on a work placement at the home. All staff spoke in private with us and were fully supportive of the inspection process. Due to the needs of the people living at the home individuals were unable to actively contribute fully to the inspection process and share their own experience of living at Hampton Road The manager of the home met us briefly as she was leaving the home to support a person who lives there on holiday. She was happy that the staff on duty would be able to support the inspection process. We reviewed in detail three care files, and looked at the records, policies and documents referred to within the report that were available to us at the time of the inspection. Given the manager’s absence some records were not available. Prior to the inspection visit the registered manager completed and returned an Annual Quality Assurance Assessment (AQAA). This document supported the homes Annual Service Review that was carried out on 18th March 2008. What the service does well: Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 6 People who live at 20 Hampton Road are supported by a team of trained and well-supported staff. Staff say that Hampton Road is ‘A happy home.’ Other staff comments included; ‘There is a good atmosphere’ ‘It is very much someone’s home’. ‘Very focused on clients and their needs’ ‘Flexible service with range of options for people’ Staff have worked very hard to ensure the person most recently admitted to the home has settled in despite some very challenging times. Staff now feel confidant that the home is an appropriate placement and that they are able to meet the person’s needs. People who live at Hampton Road were unable to share their views about the service with us at the time of the inspection but through observations and interactions it was seen that people could communicate their needs and wishes to the staff team and that they responded quickly and professionally. Staff identify and respond to changes in people’s health care needs well and seek help from professionals where necessary. Staff have good support from the manager and effective monitoring of the quality of the service provided takes place regularly from senior managers. One person said that the manager is ‘approachable, fair, understanding and a good listener’. One person said that the home was ‘well managed’ The manager stated ‘I have a smashing team and the people we support are great’ What has improved since the last inspection? Since the time of the last inspection of the home carried out by CSCI refurbishment work has taken place to improve the overall quality of the environment. This included a newly fitted kitchen, new bathroom suites and new flooring throughout. In addition the laundry walls have been painted. Requirements made by CSCI have all been actioned including improved training opportunities for staff in order to effectively meet peoples needs and risk assessments have been updated to support nighttime support. One staff member felt that interactions with people who live at the home have ‘improved greatly’ and another staff member supported this stating that they have received good support from the Community Nurse to achieve this. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 7 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 Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 9 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 Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 10 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): Standard 2 Quality in this outcome area is good Prospective people looking for a residential service can be confident that Hampton Road can support them. This is because a complete assessment of their needs is undertaken with them and others close to them, and they are given the opportunity to “test drive” the home to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection one person was having a number of trial visits to Hampton Road to ensure they liked the home, the other people living there and the staff group before they decided to move there. Significant time and effort had been put into the assessment and admission process and although it has taken a long time for the person to settle, the placement is now proving successful and staff are confident they are now able to meet the person’s individual needs. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 11 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 6,7 and 9 Quality in this outcome area is good People living at Hampton Road have a person centred plan, which informs staff about their individual needs, how they prefer these to be met and how to achieve their personal goals. People are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People are supported by their designated key workers to make decisions and choices about their lives through their involvement in their person centred plan and their support plan. It would be better if support plans held for all individuals were reviewed and updated more regularly to reflect their changing needs. This would help the staff meet their needs more effectively. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 12 Although not everyone at the home is able to express their needs verbally they can be confident that staff are familiar with their preferred communication styles such as signs, symbols, photographs and a range of pictorial formats used to aid communication. People are involved with choice and making decisions for example the person most recently admitted to the home had been fully involved in choosing the colour for their bedroom and furniture they wanted. Throughout the inspection we saw people being offered a choice of drinks, lunch and activities. It was reported that one person has an advocate and one person has a be-friender to represent their best interests. People living at Hampton Road are supported to take responsible risks to maintain and develop their independence. Assessments were available to support people in their environment, accessing the community, activities, daily living tasks and use of public transport ensuring risks are minimised. Assessments to support individuals who require assistance during the night from waking night staff have been further developed as required by our last inspection and training in managing risk has been arranged for a number of staff. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is good People living at the home are involved in daytime activities of their own choice and according to their interests and capabilities although they may benefit from more meaningful in-house activities. People are encouraged to see their friends and family and receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we arrived one person was just leaving to go on holiday supported by three staff. We were told it was the person’s first holiday in ten years and it was evident that the person was very much looking forward to it. We were told that there are plans for everyone to have a holiday again this year. One person chose to remain in bed until mid-day although was regularly checked by staff. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 14 The other two people were supported in the home although one person enjoyed a short walk. People do not currently attend external day services or college. Person centred plans detail what activities people like and dislike and we were informed that people are supported to get out into the community as much as possible but on some days not everyone gets out due to staffing levels or behaviours that challenge the service. Staff have recognised the changing needs of one individual and are trying to source appropriate activities that she would benefit from due to becoming older. A member of staff told us that one person has required lots of support when out in the community due to their behaviours but that advice has been sought to help support the individual concerned and provide new opportunities. People use the local buses, taxis and the transport provided by the home to get out and about and also walk to local shops. Observations made suggest that people may benefit from more meaningful in-house activities. Staff help people facilitate contact with their friends and families through home visits and telephone calls. It was reported that the two families who have involvement with their relatives are invited to attend reviews held but choose not to unless they wish to raise concerns. Staff said one person has a friend that they see regularly and has recently attended a party and enjoyed it. People are encouraged and supported by staff to partake in daily living tasks and their rights and independence are promoted as much as possible to include tidying their rooms, clearing the dinner table, putting the rubbish out, taking clothes to the laundry, shopping and basic meal preparation such as getting their own breakfast, making drinks and sandwiches. People are offered a balanced diet and staff are aware of people’s personal preferences and dietary needs and these are taken into consideration when planning menus. Alternatives are made available if someone chooses otherwise. The home has sought professional advice for individuals at risk of choking. Likes and dislikes are recorded in person centred plans. Hampton Road, 20 DS0000068553.V366681.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): Standards 18, 19 and 20 Quality in this outcome area is good The personal and health care needs of people are met with good evidence of multi agency working in the best interests of the people living at the home. People living at Hampton Road are generally safeguarded by the home’s systems for handling, storing and administering medication and improved systems for the ordering and returning of medication will offer further protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are aware of how individual’s prefer to be supported with their personal care needs because these are clearly recorded in their person centred plan. Observations made evidence that staff respect people’s privacy and dignity and the home provides a good balance of female and male staff. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 16 Everyone living at Hampton Road has a detailed Health Action Plan which is a plan developed by key workers and states what an individual needs to do in order to stay healthy. Due to recent changes in one person’s health and wellbeing the home has sought input from various health professionals and assessments and regular joint meetings have been held in the persons best interests. There was clear evidence that the person’s health is being very closely monitored and all appointments and outcomes recorded. Where the person has declined treatment this has been respected and this fed back into joint meetings held. A member of staff spoken with considered the home meets the healthcare needs of individuals well and that people access all routine healthcare appointments. Medication procedures were discussed with a member of staff who demonstrated an understanding of how medication is managed in the home. Records for medication administered were found satisfactory with the exception of a medication error in February 2008, when one person received two lots of medication instead of one. The action taken as a result of this was detailed in a report seen however we have no evidence that this incident had been reported to us as required. A member of staff spoken with reported that staff receive in-house training to administer medication from nurses and then they are shadowed by the manager until competent. The manager has just started assessing ongoing competency. New forms have been developed for recording all incoming drugs for each individual however we found excessive stocks held in the home, which we were unable to audit at the time of the inspection. Following the inspection we spoke with a senior manager from the organisation and she stated that she was organising an immediate audit of procedures and will ensure that stocks are ordered to meet peoples needs and additional supplies will be returned to the chemist. Hampton Road, 20 DS0000068553.V366681.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): Standards 22 and 23 Quality in this outcome area is good People are protected by procedures in place for supporting them to manage their money and listening to their concerns and complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at 20 Hampton Road have access to an easy to follow complaints procedure, which was seen displayed in the dining room of the home. The guidelines say for people to speak with the manager, key worker, carer or inspector if they are unhappy. People are reassured that all complaints will be treated as ‘confidential’. CSCI has received no complaints or concerns about this service since the time of the last inspection. Staff have received recent training, in the form of a workbook, in relation to ‘Abuse and Neglect’ and in discussions staff had an understanding of abuse and what to do if they had concerns about someone living at the home. Staff said they would speak with the manager who was described as ‘approachable’. People who live at 20 Hampton Road are supported to manage their money. Records show that every time someone spends some cash it is recorded and receipts are kept. Records also how that people’s money is checked at the start of each shift. This ensures that all money is accounted for protecting service users and the staff who support them. Staff told us that they were happy with these procedures and that they worked well. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 18 Staff who work at Hampton Road say that they receive training to support people to manage behaviours that challenge the service and there are different levels to this training. The manager should keep this under review as some staff say that they may have to manage situations that are not covered in the training. Hampton Road, 20 DS0000068553.V366681.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): Standards 24 and 30 Quality in this outcome area is good 20 Hampton Road is clean and well maintained providing people with a comfortable and safe place to live. However repairs should be carried out in a timely manner to further improve access and continued safety within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection a member of staff showed us around the home. The staff member stated that the kitchen and bathrooms have recently been refurbished and that new flooring has been fitted throughout. Staff said that people were happy with the improvements to the home and that everyone was consulted about colour schemes and furnishings. The laundry room has been painted to meet a requirement made at the time of the last CSCI inspection and staff said that people are supported and encouraged to do their own laundry. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 20 The visitor’s book showed that builders have been on site regularly and all areas looked clean and well maintained. Records showed that water temperatures were being safely regulated and the fire safety folder showed that alarms and equipment are being regularly maintained. A problem reported in March 2008 with the closing of a fire door has now been resolved although it was noted that it had taken a while to do. Records showed that the manager had recorded progress and monitored the situation. Staff said that all fire doors were now closing properly. At the time of the inspection the home was still waiting for the maintenance team to fix a magnetic door opener on the kitchen door and fit a suitable devise to the door of one person living at the home to enable her door to remain open and assist her with access to her room. This was a recommendation made by CSCI at the time of the last inspection of the home and the home’s Annual Service Review stated that ‘magnetic door devices are to be fitted in next 4 wks to allow people access to their rooms’. This had not been achieved. Hampton Road, 20 DS0000068553.V366681.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): Standards 32, 34 and 35 Quality in this outcome area is good People living at 20 Hampton Road are supported by a staff team who are trained and supported to enable them to offer a good quality of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection we spoke with five staff and observed them working with and supporting the people who live at the home. Prior to the inspection we also spoke with a member of staff over the telephone. All staff were ‘happy’. They felt well trained and well supported by the manager and other mangers who work for the Trust. One staff member said that she thought ‘people have good opportunities and the service is client focussed – clients take the lead’. Another staff member said ‘I really enjoy my job’. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 22 The rota reflected the numbers of staff on duty. One person was seen to be going on holiday with three staff, one of whom was the manager, and there were three staff left on duty to support the three people still at home. Staff told us that ‘ Staffing is adequate and will improve with new starters’. The latest staff to join the team spoke with us and said that they had received a good induction and had not been able to start working unsupported until their CRB disclosures had been received. These comments reflected the manager’s comments that no one starts work until they have received all pre employment checks including the CRB. A chart later seen on the wall in the office reflected that the manager was monitoring that all staff had all required information on their files. As the manager had left to go on holiday at the start of the inspection staff files and other formal training and support records were not formally reviewed on this occasion. A staff member who spoke with us over the phone prior to the inspection considered that recruitment processes were ‘robust’, her training was up to date and she had a National Vocational Qualification (NVQ). Minutes of the most recent staff meeting showed that people who live at the home are involved in the meetings. It was stated that moving and handling training had been planned for a date in June and staff later confirmed that this had happened and had been very successful enabling them to offer better support to someone as a result. Hampton Road, 20 DS0000068553.V366681.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): Quality in this outcome area is good People living at 20 Hampton Road benefit from being supported by an effective and open management team. The health and safety and welfare of people living at the home is promoted enabling people to be safe and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the manager of the home was just leaving to support someone on holiday. She spoke with us briefly before leaving and felt that all policies and procedures were in place and all reviews and paperwork was up to date. This was found to be the case. Staff felt well supported by the Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 24 manager. One person said that she is ‘approachable, fair, understanding & a good listener’. One person said that the home was ‘well managed’ The manager stated ‘I have a smashing team and the people we support are great’ We reviewed the latest report of a visit carried out at the home by a senior manager who works for the Trust and this showed that regular and detailed monitoring of the service takes place. The report reflected that checks took place to monitor people’s money and that the newly appointed staff had received appropriate pre employment checks and had an induction. A staff member later confirmed that the person who made this visit was very approachable, visited regularly and was also always available by phone. Records in relation to health and safety checks that are required to be carried out to ensure the home is safe were seen to be up to date. Products that are used for cleaning are kept in a locked cupboard and risk assessments support their use. Hampton Road, 20 DS0000068553.V366681.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 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 X 3 3 X 3 X X 3 X Hampton Road, 20 DS0000068553.V366681.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. Standard Regulation Requirement Timescale for action 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 YA23 Good Practice Recommendations The home should keep under review the level of training that staff receive in order to safely support people whose behaviours may challenge the service to ensure that they are trained to cover all behaviours identified within the care plans (and other records) of the people living at the home. People living at the home who use a wheel chair have previously been observed having difficulty entering their own bedroom and the door is propped open with a table. It is strongly advised that this is reviewed and appropriate door opening equipment is provided so that service users can independently access their own bedroom. The home should ensures that any building and maintenance work is completed in a timely manner to ensure the ongoing safety and independence of people living at the home DS0000068553.V366681.R01.S.doc Version 5.2 Page 27 2. YA29 3 YA24 Hampton Road, 20 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. 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