Inspection on 17/08/06 for 35 Hawthorn Road

This inspection was carried out on 17th August 2006.

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

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

Other inspections for this house

35 Hawthorn Road 09/02/06

35 Hawthorn Road 12/10/05

35 Hawthorn Road 21/03/05

35 Hawthorn Road 04/08/04

35 Hawthorn Road 23/01/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorn Road, 35 Erdington Birmingham B44 8QS Lead Inspector Kerry Coulter Announced Inspection 17th August 2006 9.35 Hawthorn Road, 35 DS0000030424.V306604.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 Hawthorn Road, 35 DS0000030424.V306604.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. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn Road, 35 Address Erdington Birmingham B44 8QS 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) 0121 384 2228 Sense West Paul McDonald Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Minimum of 3 suitably qualified staff on duty, as well as the care manager, from 7.30am - 10.00pm An additional member of care staff provided for six hours across the day All residents must be under 65 years of age That the registered manager undertakes a minimum of 21 hours dedicated management/administration time a week. Date of last inspection 9th February 2006 Brief Description of the Service: Hawthorn Road is a care home owned by Sense, who provides services to people who are deaf, blind and have associated disabilities. Hawthorn Road was first registered in December 2002, it is a traditional house, which was purpose designed to meet the needs of people with visual and hearing impairments and associated learning and communication difficulties. Hawthorn Road is currently home to five people with an age range from early thirties to early fifties. On the ground floor there is a communal lounge, a quiet sitting room and a dining room. There is a staff office, toilet and a laundry. One of the bedrooms is on the ground floor. On the first floor there is a further four bedrooms all with ensuite facilities. The home does not have a lift, so only ground floor accommodation is accessible to someone with mobility needs. To the rear of the house there is a large garden with mainly grassed area and a patio. The garden also has a brick built sun house, which has the potential to be used as additional space for service users. The pre inspection questionnaire completed by the Manager states that the fee range for the home is £1552.34 to £2887.44 per week. Copies of the CSCI inspection reports are available in the office of the home on request. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home, a pre inspection questionnaire and reports from the provider. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. Service users due to their complex needs were unable to communicate their views of the home and so time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. Staff on duty were spoken with as to their views of the home. What the service does well: The home had a relaxed atmosphere. The staff spoken with were pleasant, confident and knowledgeable in the tasks that they have to perform. Discussions with the Manager indicate a positive attitude towards training and development of the care team. Staff try to find activities that individual service users will enjoy. People, who live at the home take part in a variety of daytime activities including swimming, rock climbing, ice-skating and horse riding. Each service user had an individual Health Action Plan. This is a personal plan about what support a person needs to stay healthy and access the relevant healthcare services. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. Staff actively promote contact with service users relatives. Care plans are reviewed every six months so that if individuals needs have changed staff know how to support them appropriately. It is good that individual care plans describe how service users should be supported to make choices. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 6 Service users are well supported in their daily living tasks without losing their independence. The staff team focus on what the service user can do for themselves, rather than what they can’t. The standard of the environment within this home is good providing service users with an attractive and homely place to live. The home responds well to requirements made by the CSCI, all of the previous requirements have been met. What has improved since the last inspection? What they could do better: The content of service user risk assessments were generally satisfactory but a small minority required review to ensure the control measures in place are still appropriate. Review is needed to ensure menus are appropriate to and reflect the cultural background of the individuals who live in the home. Fire training frequency needed improving as staff were not receiving refresher training on a six month basis, this is needed to ensure staff know how to prevent fire occurring and respond safely in the event of a fire. Only five of the fifteen staff have completed an NVQ in care. However several staff are enrolled on NVQ and so this figure should rise in the future to meet the standard of 50 of staff having an NVQ. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 7 The quality assurance system needs to be fully utilised to ensure the views of service users are taken into account. 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. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and aspirations are assessed appropriately before an offer of placement is made. EVIDENCE: The statement of purpose and service users guide included all the relevant and required information. Service users were observed to have their own copy of the guide. A referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals. No new service users have been admitted since the last inspection. Evidence from previous inspections shows that a full assessment would be completed prior to the move, to include the service user, relatives and health professionals. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place to provide staff with information they need to meet service user needs. Strategies for managing risks were generally clearly identified with only minor improvement required to ensure risk is effectively managed. EVIDENCE: The care plans and risk assessments for two service users were sampled. The care plans contained detailed information to include history, medical needs, likes and dislikes, care routines, communication, issues of diversity and culture. Information was up to date. Each service user has a core team of staff, who meet monthly, to monitor the care plan, progress on achievements, goals, health care and to action any points. Minutes of these core meetings were available in the files sampled. Behaviour management strategies were observed to be detailed and included possible triggers for behaviours and strategies for staff to use to try and prevent the behaviour occurring. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 11 Where staff at the home needed advice regarding the unpredictable behaviour of one service user a referral had been made to a behavioural support team. All of the service users have very complex needs and their involvement in the day to day running of the home is limited, however observations at the time of the visit indicated that service users are encouraged to be involved in daily tasks including, removing dishes to the kitchen, making themselves a drink and bringing their washing to the laundry. Decisions and choices made by individual service users were respected by staff this included what room of the house they wanted to spend their time in. It is good that individual care plans describe how service users should be supported to make choices. A wide range of risk assessments were observed to be available for each individual. The risk assessment file contained a large quantity of assessments, some of which were duplicated, it was therefore quite a time consuming task to locate some of the assessments. The assessment for the two service users case tracked were sampled. The content of the risk assessments were generally satisfactory but a small minority required review to ensure the control measures in place are still appropriate. Hawthorn Road, 35 DS0000030424.V306604.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 and 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Intergration within the community and pursuit of leisure activities are integral elements of the ethos of the home. Staff support service users to maintain and develop relationships with family and advocates. Dietary needs of service users are generally well catered for with a balanced and varied selection of food available but the cultural needs of individuals are not always taken into account. EVIDENCE: Sampled records, discussion with staff and observation of practice show that service users are encouraged to be as independent as possible, with opportunities available for personal development. Service users are encouraged to get involved in domestic activities, communication is facilitated by various means to include body language and objects of reference. The staff team focus on what the service user can do for themselves, rather than what they can’t. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 13 Discussions with staff and sampling of records show that service users have the opportunity to participate in a wide range of activities, both at home and in the community. Each service user has an individual activity time table. During the morning of the visit all service users went out to a horse riding session. Discussion with staff indicates that the sessions are tailored according to individual need so that some service users sit on the horses whilst others go in a cart pulled by a horse. Some service users had a foot spa session in the afternoon. Staff clearly communicated the activity to them by using objects of reference, one service user was clearly looking forward to the session as they very quickly took their shoes and socks off. It is good that the home attempt to offer new activities, one service user had started to go trampolining at a local sports centre, staff said they were really enjoying this. The home has a visitor’s policy and actively encourages visits from family and friends. There was evidence that relatives also have contact by the telephone and letters /cards. Last year one service user had a been on holiday to Wales this year and was able to meet with relatives whilst there. One service user does not have any family input but has an advocate who is invited to care plan review meetings. The Manager said that when CSCI reports are received copies are sent out to relatives. It is an area of good practice that SENSE employs a Family Liaison Officer. Additionally, an annual family weekend is also arranged at a local hotel where relatives can meet with SENSE representatives and other relatives. Whilst there is some very good practice around maintaining service user contact with their family it is a strength of this home that they want to improve things further. One staff said that she intends to do some artwork with service users that they can then send out to their relatives. Observations at the time of the inspection indicated that service users are free to access all parts of the home as they wish. Service users have been enabled to use their mapping skills and at the time of the inspection they moved around the house with confidence. Where restrictions are placed on service users this is linked to risk assessments and care plans. Records of meals provided and the menu showed that a variety of food is offered. Discussion with the Manager and staff show that the menus had recently been reviewed after advice from the Dietician to ensure that portion sizes are healthy and diet is balanced. However observation of the menu shows that further review is need to ensure menus are appropriate to and reflect the cultural background of the individuals who live in the home. Satisfactory food stocks were available and these included fresh fruit and vegetables. Staff said that service users are given the opportunity to participate in shopping for food. At lunch, staff were observed to appropriately assist service users in a patient and supportive manner. However it was unfortunate that a large ring binder folder had been left in the middle of the table whilst service users ate. This detracted from the otherwise homely appearance of the dining room. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Records of health appointments evidence that service users health needs are being met. Satisfactory arrangements are in place to ensure that the management of the medication protects service users. EVIDENCE: Individual care plans detailed the support that staff needed to give to service users in relation to their personal hygiene. It was good that care plans contained a list of toiletry products the service user preferred to use. Service users were dressed appropriately to their age and gender, the weather and the activities they were doing. Each person had their own individual style of dress. Records show that service users are regularly supported to go to the barbers or hairdressers. Each service user had an individual Health Action Plan. This is a personal plan about what support a person needs to stay healthy and access the relevant healthcare services. Health professionals are involved in the care of individual service users where appropriate. These include the Speech and Language Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 15 Therapist and Dietician. Records sampled showed that service users had regular check ups with the dentist, optician and GP. Medication is stored in a locked cabinet. Medication Administration Records (MAR) had been signed appropriately. The MAR cross-referenced to the blister pack indicating that medication had been given as prescribed. Where service users are prescribed PRN (As required) medication a protocol is in place stating when, why and how this should be given. As previously required, the protocol for one service user had been reviewed to clarify the dose needed. When PRN medication had been administered staff had signed on the back of the MAR to state when, why and in what dosage they had given it to the individual. FP10 prescriptions had been copied and retained so that staff can check that the medication received is as prescribed. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints are satisfactory to ensure that service users views are listened to and acted on. Arrangements are sufficient to ensure that service users are protected from abuse. EVIDENCE: The CSCI has not received any complaints or concerns about this home in the last twelve months. The organisation, Sense, has a policy, referred to as ‘issues policy ’in respect of complaints. This was assessed as meeting the required standard at the inspection in March 2005. The Manager said that no complaints had been received since the last inspection. All of the service users at Hawthorn Road are very dependant on staff interpreting/facilitating any concerns /complaints that they may have. The complaints procedure is available in alternative formats to include audio CD. The home has a detailed Adult Protection policy and the Birmingham Multi Agency guidelines were also available. Staff at the home have received training in adult protection. Sometimes there are agency staff on duty. Profiles from the supplying agency were available to show that these staff have had Criminal Record Bureau checks completed, to ensure service users are not put at risk by unsuitable people working in the home. Sometimes the use of physical intervention has been necessary with service users to protect them, and others from harm. As required at the previous inspection the recording of these incidents has improved so that show the duration of the intervention was for no longer than necessary. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 17 Discussion with staff indicates that other behaviour management strategies are used before staff resort to physical intervention. The financial records for one service user were sampled. These were found to be satisfactory with receipts available for expenditure. It is good practice that financial audits are undertaken by Sense. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29 and 30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is comfortable, safe and homely. EVIDENCE: 35 Hawthorn Road is a traditional built house that has been adapted to meet the needs of service users. All service users have single bedrooms with ensuite. The home has a range of communal space for service users use, including a good-sized domestic style kitchen, separate dining room and two lounges. However one of the lounges is used mainly by one service user who likes their own space. Since the last inspection several rooms have been repainted and new seating in the lounge and dining room has been obtained, making the home a pleasant place. Observation of the maintenance book shows that repairs are completed quickly after being reported. During the inspection the maintenance man was visiting the home to repair an area of carpet so that it was not a trip hazard to the service users. The paintwork to the front door is starting to flake and it is therefore recommended that repainting of this area is scheduled for the near future. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 19 To the rear of the home there is a very large garden with a patio area and a large grass area with a covered pond. There is a brick sun house in the garden. A heater is available for this room so that it can be used by relatives to meet with service users in private if they wish to do so. Around the home there are tactile indicators to indicate to service users where doors, stairs and other hazards are. The lounges, dining areas and kitchens also have tactile indicators. Systems are also in place to alert the service users to someone entering the room, for example via a fan switching on. Staff spoken with said that they had all the equipment they needed to meet individuals needs. The home was found to be clean, hygienic and free from offensive odours at the time of the inspection. Liquid soap and paper towels were available for hand washing. The laundry is accessed off the main hallway and there is direct access to the garden where there is a rotary washing line. The home has a sluice cycle washing machine. Food stored in the fridge was date labelled to reduce the risk of service users from getting food poisoning. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing and their support and development are generally sufficient to ensure that an effective staff team supports service users and meets their individual needs. Service users are protected by the home’s recruitment policy and practices. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company; staff give support with warmth, friendliness and patience and treat people respectfully. Members of staff spoken with had a good understanding of the needs of the service users they work with. Only five of the fifteen staff have completed an NVQ in care. However several staff are enrolled on NVQ and so this figure should rise in the future to meet the standard of 50 of staff having an NVQ. On discussing training with staff members it is evident that the organisation is committed to training. NVQ clinics are available to staff on a monthly basis. Staffing levels are a condition of registration and the home was found to be meeting these conditions of registration. Rotas show some use of agency staff but this has not been excessive with regular agency staff being used. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 21 Staff recruitment files were sampled, these were seen to be very well organised. They contained all the information as required by regulation to include satisfactory evidence that a CRB check had been obtained so that residents are protected by a robust recruitment procedure. Sense has a rolling programme of training for staff. Home managers apply for places for staff on training courses with the training co-ordinator. Discussions with the Manager indicate a positive attitude towards training and development of the care team. Staff spoken with said they received the training they needed. The home retains copies of training certificates of staff and has a training matrix that shows all the training completed by staff, this is regularly updated. Records show that staff have received the majority of mandatory training they need, evidence was seen that for new staff training needed has been scheduled. Fire training frequency needed improving as staff were not receiving refresher training on a six month basis as it was done annually. The Manager said that he was intending to get a fire training video to assist in doing the training six monthly. Supervision records for three staff were sampled, these showed that the quality of supervisions is good and the frequency regular to ensure staff are well supported in their job role. Records show that staff meetings are held on a monthly basis, giving staff the opportunity to discuss issues important to the smooth running of the home, for the benefit of service users. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements ensure that service users benefit from a well run home. EVIDENCE: The home has a Registered Manager who has completed an NVQ 4 in care and the Registered Managers Award. It was clear from looking at outcomes for service users during the inspection that the Manager directs staff to ensure that service users needs are met. There were no requirements outstanding from the previous inspection. Systems are in place to assure quality but are not always fully utilised. Monthly visits to the home are carried out by a service manager who completes a report. Audits are also carried out periodically to include health and safety, financial, environment and outcomes for service users. Sense as an organisation has also developed a staff development plan that covers induction Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 23 and staff training. However, Sense’s annual quality assurance audit had not been completed for over eighteen months, this will need to be done. The homes fire records were observed, these indicated that regular testing of the alarms and emergency lighting is generally carried out. Certificates of servicing were available for the fire alarms. Records evidence that a recent fire drill had been conducted. Requirements from a recent visit by the West Midlands Fire Officer to the home had been actioned. During the visit it was observed that one fire door was not closing properly. This was immediately repaired by the maintenance man when brought to his attention. Up to date detailed risk assessments for the premises, risk of fire, staff and food had been completed. Staff test the water temperatures regularly, these show the water is maintained at a safe temperature. Fridge and freezer temperatures are tested to ensure food is stored at the correct temperature. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 4 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA9 YA17 Regulation 13(4) 12(1 a) 16(2 i) 18(1)(b) 23 24 Requirement Ensure that all service users risk assessments are reviewed at least six monthly. Review the menu to ensure that culturally appropriate meals are available, according to individual preferences. Ensure all staff receive fire training on a six monthly basis. Ensure that the annual quality assurance audit is completed. Timescale for action 30/10/06 30/10/06 3. 4. YA35 YA39 30/10/06 30/11/06 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. Refer to Standard YA9 YA24 Good Practice Recommendations Review the filing system for risk assessments so that assessments are not duplicated and can be quickly located. The external paintwork to the front door is starting to flake and it is therefore recommended that repainting of this area is scheduled for the near future. Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn Road, 35 DS0000030424.V306604.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!