Inspection on 23/08/06 for Nine Elms Lane

This inspection was carried out on 23rd 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nine Elms Lane 16/06/09

Nine Elms Lane 08/08/07

Nine Elms Lane 26/01/06

Nine Elms Lane 27/09/05

Nine Elms Lane 08/10/04

Nine Elms Lane 30/06/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Nine Elms Lane 87-89 Nine Elms Lane Park Village Wolverhampton West Midlands WV Lead Inspector Rebecca Harrison Key Unannounced Inspection 23rd August 2006 09:45 23/08/06 Nine Elms Lane DS0000017190.V296544.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 Nine Elms Lane DS0000017190.V296544.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. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nine Elms Lane Address 87-89 Nine Elms Lane Park Village Wolverhampton West Midlands WV 01902 833730 01902 833731 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) enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Learning Disability who may also have physical disability Learning disability with Guardianship or supervision orders under the Mental Health Act 1983 26th January 2006 Date of last inspection Brief Description of the Service: 87-89 Nine Elms Lane is a care home providing accommodation, personal and nursing care for seven adults with learning disabilities. Lonsdale (Midlands) Limited was purchased by CareTech on the 26th May 2006. Ms Catherine Johnston is the manager of the home and is yet to be registered with CSCI. The home is located in a residential area of Wolverhampton overlooking parklands. Local shops and amenities are a short walk away. The property is a two storey building providing single private accommodation, communal lounge and dining areas. The home has a passenger lift for access to the first floor. There is adequate parking to the front of the building with enclosed gardens to the rear. The fees charged per person range from £1,100 to £1,300 per week. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 09.45a.m. and lasted just over five hours. It was carried out by talking with service users present at the home, the manager, staff on duty, case tracking two service users, observation of some work practices, examination of a number of records and a tour of the home. The purpose of this inspection was to review the progress made since the last inspection undertaken on the 26th January 2006 when five requirements were made. 21 key National Minimum Standards for younger adults were assessed during this inspection and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, staff and managers were very welcoming and co-operated fully throughout the inspection. Since the last inspection one complaint has been received by the home with a satisfactory outcome. No complaints have been referred to the Commission for Social Care Inspection and there have been no referrals made under adult protection procedures. What the service does well: It is difficult to accurately represent the views of the people using the service in relation to the quality of care they receive given the service users abilities and the limited opportunity to fully observe staff practice given the needs of one individual during the inspection. However discussions held with a visiting relative, the manager and staff on duty indicate that people are supported by a very committed and highly motivated staff team. It is evident that the management approach of the home creates an open, positive and inclusive atmosphere which service users clearly benefit. Staff have a good understanding of the people’s individual needs and have developed positive working relationships with the people they support. Links between service users and their families are well established and promoted. A relative spoken with during the inspection was very complementary regarding the service provided, the staff and in particular the new manager. Service users are provided with good social and educational opportunities. Activity records evidence that people lead active lifestyles. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Since being appointed the manager has reviewed and updated service user care plans and is clearly looking forward to developing these further using a person centred format. A service users guide needs to be developed and made available to service users and representatives. A development plan for the home should be developed and the views of families and stakeholders sought on how the home is achieving goals for the people accommodated. One staff member reported that she would like to see service users out more but funds and adequate places to go are limited. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 7 Some staff are in need of refresher training in safe working practices and the manager has recently booked places on forthcoming training events. 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. Nine Elms Lane DS0000017190.V296544.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 Nine Elms Lane DS0000017190.V296544.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 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new person to the home. EVIDENCE: The Statement of Purpose has been revised to reflect the managerial changes and a copy of this was provided to the inspector. The manager committed to updating the document to reflect the purchase of the organisation by Caretech Community Services Ltd who acquired Lonsdale (Midlands) Limited on 26th May 2006. A requirement has been made at previous inspections for a Service User Guide to be developed and made available to all service users and their advocates. Discussions held with the new manager evidence that this requirement remains outstanding however the manager is keen to develop a guide in a format appropriate to the current people accommodated. There have been no new admissions to the home for a long time therefore it was not possible to assess key standard 2 on this occasion. The home currently has no vacancies. A Contract of Residence was not available on the files of the two people case tracked. A blank contract is included in the homes Statement of Purpose Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 10 however this needs to be amended to reflect the changes in ownership and a signed copy made available to service users. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current service users are unable to contribute to the assessment and care planning processes due to the nature of their disabilities. However, there are care-planning systems in place to adequately provide staff with the information they need to meet the assessed needs of the people accommodated. Service users are supported to take risks within a risk-assessed framework. EVIDENCE: One requirement was made as a result of the last inspection for care plans to accurately reflect the care being provided. Two service users were case tracked and their files reviewed at length. A pen portrait was available on both files providing staff with a brief history of the individual. An activity of living in addition to a care plan was available on file with evidence of review by the new manager. Records seen evidence that one individual case tracked has been formally reviewed by the home and significant others since the last inspection. A formal review arranged for the other person case tracked has been cancelled on two occasions by the placing authority and a further meeting has been Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 12 scheduled. It was reported that formal reviews have been held for three out of the seven people accommodated. Although information on the care files reviewed is basic, staff spoken with were confident that they are provided with sufficient information for the delivery of care and demonstrated a good understanding of the individual needs of the people they support. Daily records were comprehensive. The manager reported that all care plans have been reviewed and updated since the last inspection. She is waiting the arrival of new care documentation provided by CareTech to transfer relevant information and develop support plans further. Person Centred Plans (PCP’s) have yet to be developed and this was fully acknowledged by the new manager who has an understanding of PCP’s but has not yet undertaken training in this area. The new manager has recently completed ‘Staircase model’ behaviour plans for the people accommodated and these were available on the files reviewed. The plans seen provide staff with clear guidelines on how to respond positively to behaviours that may challenge. These plans were developed with the support of the staff team who have worked with the individuals for a number of years. It was reported that none of the service users have an independent advocate due to the difficulties with obtaining this service, therefore the manager, named nurses, allocated key workers and families represent the people living at the home as much as possible. During the inspection service users were provided with opportunities to engage with making decisions and were supported appropriately. A variety of risk assessments were available on the files reviewed for in-house and community activities in addition to moving and handling assessments, risk of falls and waterlow pressure sore assessments. There was evidence of review and a referral made for specialist equipment for an individual assessed as very high risk. Discussions held with the manager evidence that precautionary measures have been made in the interim for the person concerned. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, 15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with social and educational opportunities within the community. They are provided with a balanced diet, their rights and responsibilities respected and links with families and friends are promoted. EVIDENCE: It was reported that four of the people attend day services provided by the local authority. One person also attends a local college. One individual case tracked attends a day service full time and appears to enjoy attending this provision. Activity sheets evidence that the person leads an active lifestyle and regularly enjoys accessing a range of community activities and events. The activity records for the other person case tracked evidence regular visits to a variety of parks and visits to relatives. Records state that the person’s physical condition and persons own wishes determine any activities followed on a daily basis. During the inspection she was being supported by staff and appeared happy. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 14 Discussions held with a visiting relative, the manager and staff on duty evidence that links between service users and their families are actively promoted. A relative spoken with during the inspection was very complementary regarding the service provided, the staff and in particular the new manager. She reported that she attends formal reviews held and is always kept well informed by the team. She considered that her relative’s needs are well met and that he appears happy living at the home. During the inspection the manager supported one individual to make telephone calls to two of his relatives. Records seen and discussions held with staff on duty indicate that people are encouraged to develop their self-help skills as much as their ability allows. During a tour of the environment the manager was seen to knock on service users rooms prior to entry and the privacy of individuals promoted. Requirements have been made at previous inspections for service users to be provided with wholesome, nutritious and varied meals. The menu available offered choice and variety. The manager and staff on duty reported that they are in the process of taking photographs of various meals in order to develop a pictorial menu to assist service users with choice. Personal preferences and completed food diaries were available on the files of the two people case tracked and these appeared balanced. It was reported that one individual has special dietary needs, which the home is able to cater for in addition to one individual from an ethnic minority group. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are met with evidence of regular review with healthcare professionals. The home has an effective system for handling, storing and managing medication which safeguards service users. EVIDENCE: The healthcare records of the two people case tracked were detailed and evidence that service users health needs are closely monitored and kept under review. Service users present at the inspection appeared well presented and preferences in relation to personal support were documented on the two care files reviewed. Each individual is provided with a key worker in addition to a named nurse and the staff spoken with were knowledgeable in relation to the healthcare needs of the people accommodated. Health records seen evidence that individuals are supported to access NHS healthcare facilities and the outcome of all appointments recorded. Appropriate referrals have been made on behalf of one person whose healthcare needs have increased. A letter seen on file from a general practitioner indicated that the home invited him to attend a persons review. Health Action Plans have yet to be developed. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 16 Procedures for the handling, storage and management of medicines appeared satisfactory at the time of the inspection with the exception of two gaps found in the medication administration records (MAR) for one individual. Discussions held with the manager and scrutiny of daily records evidence that the person’s medication had been administered but not recorded on the MAR chart. The manager reported that only qualified staff administer medicines and agreed to address the shortfalls found with the staff members concerned. Medication storage was found well organised. The manager reported that the homes medication procedures have been inspected by a local pharmacist and found satisfactory. None of the service users are currently prescribed controlled drugs although appropriate storage facility is available. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system in place and procedures to safeguard service users from potential abuse. EVIDENCE: The home has a complaints procedure in place, which the manager committed to update to reflect the local contact details for CSCI. Discussions held with a visiting relative evidence that she was unaware of the complaints procedure for the home however she stated that she has never has cause to make a complaint and any concerns would be shared with staff and the manager in the first instance. No complaints have been referred to the Commission for Social Care Inspection (CSCI) since the last inspection. The home has received one complaint and the outcome of this was shared with the inspector and the situation resolved following a meeting with all parties concerned and the care manager from the placing authority. Two complements have been received from relatives expressing satisfaction with the ongoing care provided and support of the designated key worker. Another reported satisfaction with their relative’s personal appearance and general state of health. No referrals have been made under adult protection procedures since the last inspection. Training records evidence that some staff have attended training in adult protection in the local procedure however some staff still require this training. The manager reported that the majority of staff have attended training in Non Violent Crisis Intervention (NVCI) and she is booked to attend such training in November. It was stated that no service users have been subject to physical intervention. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 18 The finances of the people case tracked were inspected and were an accurate reflection of the records held for one individual and were three pence over for the other. It was reported that only qualified staff handle service users finances and monies are audited as part of Regulation 26 visits and checked and signed by two staff during staff handover. Service users currently do not have their own bank accounts however this may be reviewed under CareTech. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a comfortable, clean and homely place to live. EVIDENCE: A full tour of the home was undertaken. Since the last inspection a number of improvements have been made to provide people with a more homely and safer environment to live. A new level access shower facility has been installed on the first floor. Systems to safeguard service users and staff at night have been installed and the rear garden has been landscaped and new paving, ramp and fencing provided and service users have been involved with planting out borders and tubs. The manager reported that improvements to the front garden have also been made and fencing at the side is due to be completed to fully safeguard service users. Bedrooms were found personalised and well maintained. New furniture is currently on order for the dining room and lounge, which will further enhance the environment for people in residence. The home was found clean and tidy during this unannounced inspection. A cleaning schedule is in place. An odour was detected in the lounge area and the manager reported that the carpet would be steam cleaned shortly. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 20 Products hazardous to health are appropriately stored and data sheets and quick reference information charts available in addition to personal protective equipment, hand towels and soap. It was reported that staff have undertaken training in infection control. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: In addition to the manager there are thirteen staff employed providing 24-hour support at the agreed levels with first level nurse cover and support workers. The manager reported that three staff are NVQ qualified and the remainder of support staff are undertaking the award. One qualified nurse is currently undertaking NVQ level 4 Care and another is currently undertaking the Registered Managers Award. Discussions held with two staff evidence that they are clearly committed to their work, highly motivated, keen to learn and have a good understanding of the individuals they support. It is evident that staff morale is high and that the team functions well. The personnel file of one person appointed since the last inspection was reviewed and contained the relevant information as required by Schedule 2, of the Care Homes Regulations. The person appointed had previous care experience and an NVQ level 2. It was reported that CRB disclosures are retained at the Head Office however the CRB disclosure number was documented. The manager stated that the home has no staff vacancies. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 22 The new manager has developed a team-training plan for 2006/07 identifying individual staff training needs and has updated the training matrix for the team. Training booked includes mandatory training in addition to NVCI (physical intervention) and adult protection. Individual training records are maintained on personnel files. Discussions held with the manager evidence her commitment to providing a well-qualified workforce. A requirement was made at previous inspections that all staff receive formal supervision at least 6 times a year and an annual appraisal. The manager confirmed that since her appointment all staff have received formal supervision. A supervision matrix has been developed and the manager stated that she is responsible for supervising qualified staff that in turn supervises the rest of the team. Monthly team meetings are in place and an agenda for a forthcoming meeting was seen displayed in the staff room. The new manager has not yet had opportunity to undertake staff appraisals. Nine Elms Lane DS0000017190.V296544.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by a competent manager who leads her team with confidence creating an open and positive atmosphere from which the service users benefit. Aspects of performance are currently being reviewed. The premises are maintained in a safe manner promoting the health, welfare and safety of service users. EVIDENCE: Since the last inspection Ms Catherine Johnston has been recruited and appointed as manager of the home. Ms Johnston reported that she has recently submitted her application for registration with the CSCI. She is contracted to work 37 hours per week. The manager reported that she is a registered learning disability nurse and obtained NVQ level 4 Care and is currently working towards the Registered Managers Award. She has Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 24 numerous years experience within the learning disability field and appears well organised. Staff spoken with were extremely complementary regarding the managers leadership skills, the positive changes she has made, increased staff morale and her commitment to the post. Discussions held with the manager and observations made, evidence that she is very service user focused and clearly enjoys her role. A requirement was made at the previous inspection that quality assurance and monitoring systems be developed and maintained. Since the acquisition by CareTech the manager has recently been provided with a Residential Care Standards quality assurance audit tool that she is currently working through with the team. She reported that she has also sought advice from the Quality Assurance Officer and has not yet had the opportunity to seek the views of others on aspects of the homes performance. Monthly visits and reports are undertaken as required under Regulation 26 and a copy of the report forwarded to CSCI. Reports evidence that vast improvements are being made. Health and safety procedures appeared satisfactory at the time of this inspection. Accident records, temperature monitoring charts, staff training and service certificates were reviewed and satisfactory with the exception of some mandatory training, which has been identified and booked. An external company undertook a health and safety audit in June 2006 and the manager is currently addressing the recommendations made. The homes health and safety policy was not reviewed on this occasion however the manager confirmed that she is satisfied with the health and safety arrangements in place. It was reported that the neither the Fire Officer or the Environmental Health Officer have visited since the last inspection of this service and that the requirements made by the fire officer on 02.09.05 have been met. The manager reported that she has recently undertaken a fire assessment for managers training course and is currently working on the fire risk assessment for the home as required. Records for testing and the servicing of appliances were available and valid. Nine Elms Lane DS0000017190.V296544.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 2 2 x 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 3 4 2 x x 3 x Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement A service users guide must be developed and made available to all service users and their advocates. (Previous timescale of 30/11/04, 30/11/05 and 28/02/06 not met). Each service user must be provided with a copy of the contract signed by the manager and a representative of the service user. All staff members must have an annual appraisal. (Previous timescale of 30/11/04, 30/12/05 and 28/02/06 not met). An annual development plan for the home must be developed and views sought on how the home is achieving aims for service users and results published. Timescale for action 31/10/06 2. YA5 5(c) 31/10/06 3. YA36 18(2) 31/10/06 4. YA39 24(1) 30/11/06 Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA19 Good Practice Recommendations It is recommended that person centred plans be developed and implemented as soon as possible. It is recommended that health action plans be provided as soon as possible. Nine Elms Lane DS0000017190.V296544.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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