Inspection on 03/08/06 for Noire House

This inspection was carried out on 3rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Noire House 23/07/07

Noire House 01/02/06

Noire House 04/08/05

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 Noire House 31 Abbotts Road Erdington Birmingham West Midlands B24 8HE Lead Inspector Joe O`Connor Unannounced Key Inspection 3rd August 2006 11:00 Noire House DS0000064613.V302665.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 Noire House DS0000064613.V302665.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. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Noire House Address 31 Abbotts Road Erdington Birmingham West Midlands B24 8HE 0121 382 0217 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) Robinia Care West Midlands Limited Nigel Alan Ward Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 The manager must obtain an NVQ Level 4 in Management or equivalent by July 2007. 1st February 2006 Date of last inspection Brief Description of the Service: Noire House is a modern purpose built home at the end of Abbotts Road in Erdington. It provides accommodation to four people with learning disabilities. The house feels light and airy with a homely atmosphere. To the rear of the property is a large garden, which surrounds both sides of the premises and is laid to lawn. There is no off road parking. The ground floor of the premises consists of a large lounge, with a conservatory that is used as a dining room. There is also a large kitchen, which is occasionally used as a second dining room. A toilet, separate laundry area and office are also located on the ground floor. There are four single bedrooms on the first floor, all of which are a good size and a bathroom with a shower. The service is well situated for local amenities such as Erdington, Star City and The Fort retail park. It is also close to bus routes for Birmingham City Centre and Sutton Coldfield. The premises does not have access for people with mobility difficulties. The range of fees charged by the service range from £1035.23-£1447.94 There are currently no additional charges. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over a day and the fieldwork was unannounced. Three people who live in the home were able to provide some comments about life in the home. The Inspector spoke to the Registered Manager. Comments were received from all of the service users and four staff members who had completed CSCI survey forms. A partial tour of the premises was undertaken. Care records including care plans risk assessments were sampled. Other records examined included staff recruitment and training and those for health and safety. Additional information was also examined from the pre-inspection questionnaire that is sent out to the home before the fieldwork visit along with a history of the home including any significant events. Some indirect observations of care practices were also undertaken. To see how the home has performed since the last inspection then the report should be read with the unannounced inspection report 1 February 2006. What the service does well: Everyone lives in a building that is clean, comfortable tidy and safe environment for the people living there it is maintained to a good standard. The CSCI received four surveys from the people who live in the home as well as three from the staff who said they thought the building was clean and tidy which is good. Two people provided comments about what they thought about the home. One said, “ I like it here the staff are very nice”. Another said, “It’s nice here but I would like to have bank card to withdraw my money”. Observations were made of how people were being supported by the staff who provided appropriate support including one who encouraged one person to change their T-shirt after it had become dirty when he had returned from his day centre. The people who live in the home are a mixed group with one Asian and White Irish man and two White females. It was good to see that both men were able to maintain links with their cultural background. For example one of the men who is a Sikh had posters and symbols of his religion in his bedroom. He also has his own Bhangra music tapes and goes to the Star City cinema complex to watch Bollywood films. There is a member of staff who works in the home who is able to communicate in his main language of Punjabi. The other man living in the home went to the St Patrick’s Day parade this year and was pleased to be wearing his Republic of Ireland football shirt. Both women get appropriate care and support from female staff. The manager said new staff were being recruited including a white male so there would be a better balance of care for the men. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. The service continues to meet the needs of the current group of service users who receive appropriate professional support from staff. Standard 2 not assessed. EVIDENCE: Two service users spoken with said they were happy with the support they were receiving from the staff. One said, “I like it here and the staff are nice”. Another said, “ The staff are nice but I would like to have my own bank card”. One service user who has limited verbal communication nodded his head and smiled to indicate that he was happy living in the home and used sign language to show that he liked going out for a drive with staff. An examination of two service users’ care records indicated they had been reassessed and reviewed by social workers since the last inspection. There copies of their assessments on file with an updated care plan. These had been reviewed as part of the Local Authority’s financial review of support hours provided by the organisation. The manager stated there were no significant issues identified during the review process. Observations during this inspection indicated the service users were receiving appropriate support from the staff. It was observed one service user who had Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 9 returned from their day service with a badly stained T-shirt was encouraged quietly by one member of staff to change it. Noire House DS0000064613.V302665.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, 8, 9 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. How service users needs are to be addressed are set out in detailed care plans but service users should be involved in their development. Service users risks are identified and how these should be minimised are recorded for support in the home and in the community. Service users are involved in making decisions about the running of the service through weekly meetings. EVIDENCE: The manager has introduced a new care plan format as part of reviewing the care records. One care plan being developed was very detailed and specific with its aims and objectives and how these should be addressed. This care included in formation as to the kind of activities the service user would like to do such as going to the pictures. The care plans also had pen pictures, which contained information about their daily routines including the individual’s preferred time getting up and going to bed. Another care plan seen had eating guidelines, which stated the service user must have their food cut up. Two service users were asked if they knew if they had a care plan and both said they didn’t know. The manager must ensure the revised care plans provide evidence of the service users’ involvement. The current care plans had been Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 11 reviewed and evaluated since the last inspection. Each service user has have photo wallet called This is Me, which includes photographs of the person and the people involved in their lives. One included information such as the professionals involved in their care. One referred to a service user enjoying Bhangra music. Some work had been carried out to improve these but one did not have one individual’s likes and dislikes and nor was there a reference to their cultural requirements as an Irish person or what was their religion. The manager commented that he was looking to link up with an appropriate training provider to undertake person centred planning training. Two service users stated there were meetings every Sunday where they talk about what they wanted to add to the food menu and future activities and a new vehicle. There minutes for these and there was some evidence indicating the service users had been involved in choosing their forthcoming holiday to Devon. The format for uses a combination of illustrations and symbols. Two service users who had been supported to complete CSCI surveys had ticked to say that sometimes they were involved in making their own decisions each day. Risk assessments were in place for each of the service users’ care records examined. These included how people were to be supported in the home and when out in the community. One service user had a risk assessment covering road safety. Another referred how it important it was not to leave the service user unsupervised when having a bath due to their past history of epilepsy. Noire House DS0000064613.V302665.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): 12, 13, 14, 15, 16, 17 Quality outcome in this area is adequate. This judgement has been based on available evidence including a visit to the service. Service users are able to access the community but they must have the opportunity for a wider choice of activities than what is currently being provided. Service users have good relationships with staff and are supported to maintain contact with their families. Service users do not have enough opportunity to prepare their meals to enhance their independence. EVIDENCE: Two of the service users currently attend a day service provided by the Local Authority and transport is provided by the day centres. The remaining service users have a programme of activities including shopping, horse riding, bowling, college sessions and relaxaway, which is a multi sensory facility. When examining the activity and daily diaries it was noted the service users had been out to the cinema, pub lunches, and trips out to Birmingham Botanical Gardens and recently went out for the day to Weston –Super Mare. One of the service users who is of Asian origin goes out to Star City Centre where he is able to watch Bollywood films and has these on video and DVD. The manager said he was making arrangements for the service user to have his favourite Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 13 Bhangra music on CD as he had a tendency to break the cassette tapes. One of the service users is of Irish descent and the manager and a member of staff confirmed that he and the other service users had been taken to the St Patrick’s Day parade in March this year. The service user concerned was pleased to show his football shirt of the Republic of Ireland. Three CSCI staff surveys received following the fieldwork visit commented they thought what the home does well is provide a lot of activities but also thought additional staff were needed to enable the service users to have even more activities during the week. All the service users will be going on holiday to Totnes in Devon in September this year. Two said they had chosen where they wanted to go and were looking forward to it. The manager commented that although everyone is going together, the staffing support being provided means that the service users will be able to pursue activities and trips of their own choice. A new seven seater vehicle had been purchased since the last inspection. Records have now been introduced to indicate where service users had been involved in domestic tasks such as laundry, polishing vacuming, setting and clearing tables and washing up. It was noted however, that the daily recording of service users’ was mostly brief and did not fully reflect how service users had spent their leisure time and their interaction with staff. One service user commented how much she enjoys doing cookery at college but did have the opportunity to do this in the home. The manager has introduced a four week menu that has a range of photographs to try and make it more easy for the service users to choose what they want to eat. There was evidence to indicate service users were being offered a range of nutritious meals but the food intake records tended to be repetitive in what had actually been consumed. The service users were observed to be having their tea in the garden, which was chicken curry and rice. The meal was not sampled but it appeared well prepared and the service users were enjoying it. An examination of the food cupboards, refrigerator and freezer found these were well stocked with items bought from reputable suppliers. The service users are able to maintain contact with their relatives. One of the service users has home leave with his parents on Sunday and is taken to their local Gudwara temple. Another service user said sometimes she has visits from her brother. Observations at the time of this inspection indicated there was a good relationship between the service users and staff. Noire House DS0000064613.V302665.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, 20 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users are receiving assistance and support with their personal healthcare and support when this is required. EVIDENCE: The service currently accommodates two White English Females and two males one Irish the other who is of Asian origin. The staff team currently comprises of mainly White female English origin with currently no males on the residential staff team. The manager said that two new staff members had been recruited including a white male to provide much needed support for the male service users. Two care plans sampled referred to service users’ gender care preferences. There is an Asian female member of staff who speaks Punjabi, which is the same language as the service user who is a Sikh. An examination of three service users’ care records referred to where they had assistance with or completed personal their personal care tasks including a bath, wash or shower. One care plan sampled referred to how the service user should be supported with their oral care while another had detailed guidelines in place for the management of their diabetes. There were also protocols in place for the monitoring of blood sugar levels. Each service user has a manual handling assessment, which were approaching their date for review. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 15 There was documented seen confirming that service users were able to access community healthcare services including GP, Dentist, Chiropodist and Optician. Each person has a yearly health plan that refers to treatment service users had received during the year. Care records indicated service users were had medication reviews from a Consultant Psychiatrist. Each service user had a record of their weight, which was carried out every month. It was good to note that service users go out to the local hairdresser rather than have one visiting the home. Medication management was to an acceptable standard. An examination of the Medicines Administration Records (MAR Sheets) found there were no gaps in recording. Written protocols were in place for the use of PRN medication including the use of rectal diazepam. Consent had been obtained from one service users for the service to administer their medication. There were records in place of staff medication audits, which were completed weekly. Two members of staff have recently enrolled for accredited medication training. Noire House DS0000064613.V302665.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, 23 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users have access to an accessible complaints procedure that informs them any complaint will be acted on. Service users interests are adequately protected with good systems in place for the management of their personal monies. EVIDENCE: An examination of the pre-inspection questionnaire and the home’s complaints record indicated neither the service nor the CSCI had received any complaints since the last inspection. Two service users said they would go to the manager if they were unhappy about the support they were receiving. The complaints procedure combines the use of a words and symbols format. There is also a complaints procedure on display in the hallway with details of the CSCI and a photograph of the Inspector was also on display. Since the last inspection the organisation has linked up with an accredited training provider called Team Teach for physical awareness. The majority of staff had been booked for this training during the remaining half of this year. There is a copy of the latest adult protection multi agency guidelines published by Birmingham Social Care & Health. An examination of two staff records found they had completed training in awareness of adult abuse. Two service users’ personal allowances were examined. There were records in place confirming money coming, what had been spent and for what purpose. Receipts were also attached to the records. Two signatures were generally in place for all transactions. The service users’ monies are stored in their own purses or wallets and locked in a safe in the office. The financial records are checked by staff at each handover. The pre-inspection questionnaire states Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 17 that the organisation operates a client money system where each service user has their own interest bearing account. Statements are issued quarterly and copies are kept on the service users’ files. A requirement from the last inspection for one of the service users’ to have a written agreement for the use of their Motability vehicle had been addressed. The manager provided a copy of the agreement following the previous inspection although the Motability contract agreement had now expired and that the service user was being paid his DLA Mobility Component. Noire House DS0000064613.V302665.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, 30 Quality in this outcome area is good. This judgement has been based on available evidence including a visit to the service. Service users live in clean, tidy accommodation that is maintained to a reasonable standard. EVIDENCE: A partial tour of the premises was undertaken and it was generally clean and tidy. The manager stated plans were in place for the hallway, office, lounge and landing to be re-decorated. Improvements had been made to the grounds at the side of the building. This included the introduction of a green house and vegetable patch. Improvements had also been made to the back garden, which was recently entered in the organisation’s best garden competition. CSCI surveys from all of the service users and three from staff thought the building was clean and tidy. There are procedures in place for the control of infection and one member of staff was observed to be wearing a protective apron when preparing tea in the kitchen. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 19 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, 36 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users are supported by staff who receives regular training and supervision to meet their needs. Service users interests are protected with robust and safe recruitment practices in place. EVIDENCE: The pre inspection questionnaire stated that out of eight care staff employed in the service 90 of these had achieved qualification towards NVQ Level 2 and above. This was also confirmed when examining staff training records, which were being updated by the manager. Two members of staff have enrolled for NVQ Level 3 training. A requirement from the previous inspection for all staff to bring in copies of their NVQ certificates confirming evidence of qualification had been addressed. A new member of staff commenced training for the Learning Disability Award Framework (LDAF). Since the last inspection the manager had developed a training matrix and it was noted a number of staff were having updated training in areas such as first aid, manual handling food hygiene, adult protection and fire safety. Two staff training records sampled they had completed training in areas such as epilepsy and makakton. One CSCI staff survey received commented that the current training venues used by the organisation in Burton Upon Trent and Coventry were too far for some staff to travel. However another comment was Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 20 made that the training provided was well done and they could do any course they wanted to. The manager commented that he was looking to identify alternative training venues in the Birmingham area. Two staff recruitment files were sampled including one for a newly recruited member of staff. There was evidence of a job application form, job description, two references, proof of identity including a photograph, CRB check, medical questionnaire and induction records. The staff records indicated that staff were receiving supervision every month and appraisals were being undertaken. The pre inspection questionnaire stated one member of staff had left since the last inspection. It also stated 8 shifts had been covered by bank staff over the previous eight weeks. Three CSCI staff surveys commented that more staff were needed so that the service users could have more activities. In discussion with the manager he stated two new staff had been recruited and would be commencing their duties later in August 2006. The manager stated that once the new staff have completed their induction the rota will be revised so that there is enough staff on duty during the evenings and weekends giving service users more opportunities to go out. An examination of the staff rota four the previous four weeks indicated staffing levels had remained unchanged since the previous inspection. In the hallway there is a board with photographs of staff to assist the service users to identify who is on duty during the day. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 21 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, 41, 42 Quality outcome in this area is good. This judgement has been based on available evidence including a visit to the service. Service users are benefiting form a service that is well managed protecting and maintaining their health and safety. EVIDENCE: The manager was registered with the CSCI following the last inspection and stated he had completed his NVQ Level 4 and has almost completed his training towards the Registered Managers Award well within the timescale of July 2007. He spoke positively that staff were working hard towards managing the changes particularly with new systems of recording. The manager stated that staff would soon be offered new contracts with Robinia and that there would also be rises in salary, which would be an improvement in what staff are currently receiving. Two staff spoken with stated they were getting used to the changes especially with the documentation but were happy with progress so far. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 22 A representative of the organisation visits the service every month and reports of these visits were available for inspection. There was evidence service users and staff were able to comment about the management of the service. The manager responded to any issues identified during these visits with an action plan. Service users had completed satisfaction surveys provided by Robinia during June 2006. The formats used for these combine the use of pictures, symbols and printed word. The comments viewed on these indicated the service users were satisfied with the support being provided. A satisfaction survey had also been completed by a relative, who stated he was satisfied with overall care being provided for his relative. The records were generally up to date and locked secure protecting service users’ confidentiality. Health and safety records were examined and these were satisfactory. There was evidence confirming the fire alarms were being tested every week and the emergency lighting every month. A fire drill had occurred prior to this inspection as had staff fire training. There was a risk assessment for the prevention of fire. A fire procedure is on display, which is available in a picture and symbol format. The gas and electrical equipment had also been inspected and serviced. The risk assessment for the premises had recently been reviewed. The accident book was examined and it was noted seven had occurred since the last inspection and all of these had been notified to the CSCI. Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 23 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 N/A 2 N/A 3 3 4 N/A 5 N/A 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 N/A 26 N/A 27 N/A 28 N/A 29 N/A 30 3 STAFFING Standard No Score 31 N/A 32 3 33 3 34 3 35 3 36 N/A CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 N/A LIFESTYLES Standard No Score 11 N/A 12 2 13 2 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 N/A 3 N/A 3 N/A 3 3 N/A Noire House DS0000064613.V302665.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1)(2) Requirement The Registered Person must ensure service users care plans provide evidence of their involvement in the development and review process. Timescale for action 03/10/06 2. YA12 YA13 16(2)(i) Me and My Life Books for all service users must make reference to individual spiritual and cultural requirements. The Registered Person 03/10/06 must ensure that service users are provided with a wider range of activities of their choice during the evenings and at weekends. The daily diaries must contain more evidence of how service users spent their leisure time and reflect how staff interact and provide support. The Registered Person must ensure the records of food eaten by service users during the week demonstrate that staff are DS0000064613.V302665.R01.S.doc 3. YA17 16(2)(1) Sch4 (13) 03/10/06 Noire House Version 5.2 Page 25 encouraging healthy eating options. Service users must be given opportunities to prepare meals in the home. The Registered Person must ensure he provides written confirmation that he has completed the Registered Managers Award. 4. YA37 9(2)(b)(i) 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Noire House DS0000064613.V302665.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 Noire House DS0000064613.V302665.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. 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