Inspection on 24/01/08 for Patricia House

This inspection was carried out on 24th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Patricia House 12/02/09

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 Patricia House 266 Warwick Road Accocks Green Olton Solihull B92 7AE Lead Inspector Llynn Woods Key Unannounced Inspection 24th January 2008 09:00 Patricia House DS0000070434.V356397.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 Patricia House DS0000070434.V356397.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. Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Patricia House Address 266 Warwick Road Accocks Green Olton Solihull B92 7AE 0121 681 1448 0121 681 1448 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) Middleway Care Ltd Wendy Dobson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: either, whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD (maximum number of places 5). The maximum number of service users who can be accommodated is 5. This is the homes first inspection since registration in September 2007. 2. Date of last inspection Brief Description of the Service: Patricia House is a large detached property located in the Solihull area of Birmingham. It is set well back from a busy main road and to the frontage has dedicated off road parking. The home is close to the shopping centre at Acocks Green, which has numerous shops, public houses and other local amenities. The town centres of Solihull and Birmingham can be accessed by public transport. The gardens are situated to the rear of the property. There is ramp access leading to the front door and into the rear garden. The Home was initially registered in September 2007 to provide care for five adults with a range of learning disabilities. Resident accommodation is on the first and ground floor. Staff offices, sleepin and shower facilities are on the second floor. The Home does not have a shaft lift or stair lift. All residents accommodated on the first floor are fully mobile. There are five single bedrooms all with shower or wet room en-suite. The Home has a communal bathroom on the first floor for residents who prefer to bath but this is only accessible to those without restricted mobility. Residents bedrooms are all decorated individually and reflect residents differing tastes and personality. Residents can bring some of their own furniture if they wish. There are toilets located on the ground and first floors. There is a pleasant open plan lounge and dining area leading to a raised decked patio overlooking the rear garden. A statement of purpose and service user guide are available to inform residents of what they can expect at the home. Details of the full range of fees paid by residents at the home was not available. Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This was a key inspection site visit of this service that was undertaken on 24th January 2008 and included formal feedback to the registered manager on the evening of the 24th. In total the visit took approximately 10:25 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included looking at information the service provides for prospective residents, their carers and any professionals. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, some staff and two residents were spoken to during the site visit and a brief tour of the home was undertaken. Where residents were not able to communicate their views about the home or their care experience an opinion has been made from observing interactions with staff and other residents. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to residents, relatives and to some professionals that have involvement in the service. Staff surveys’ were handed out during the site visit. Five staff surveys were returned along with two service user surveys. Parents completed surveys on behalf of the resident. The main points are included in this report. What the service does well: Patricia House provides a friendly and welcoming environment where residents were relaxed and at ease in their surroundings. Relationships with staff seemed to be very good. Residents have a very active life inside and outside the home, are able to choose what to do and are helped to live independent and fulfilling lives. Care plans are detailed and show that the staff know and understand how to deliver the care required. Residents said that as much as possible they were involved in the writing of their care plans and in some instances had signed to show that they have been consulted about what happens in their lives. Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 6 The home knew about the health needs of residents and records showed that residents were supported to attend health appointments so that their good health could be monitored. We have received no complaints about this service and there were no recorded complaints at the home. The home has made efforts to ensure that service users feel that they can raise any concerns they may have, by providing a user friendly complaints procedure and discussing concerns at service user meetings. Residents said that “staff help me if I have any problems” and “I know how to make a complaint if I’m unhappy but I don’t have anything to complain about”. To the benefit of residents the staff team seemed to work well together. They also clearly showed throughout this visit that they have a good understanding of the needs of the residents. There is good communication between staff and meetings take place regularly so that information can be shared. The home knows the training staff need so that they can give appropriate care to residents and the arrangements for training to happen are good. 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. The summary of this inspection report can be made available in other formats on request. Patricia House DS0000070434.V356397.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 Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good The home provides information; in a format people can understand to help them to make an informed decision about whether they want to live at the home. Before moving into the home the needs and aspirations of people are fully assessed so that plans can be made for the home to meet individual needs. EVIDENCE: The home has a statement of purpose which has enough information in it so people thinking about living at the home can make an informed decision about whether they want to move in. This information is also available in alternative formats suited to resident understanding, (Symbol). Before residents move in, the home makes sure they know what the needs of people are so that they can tell if the home is the right place for them to live and so that they can arrange to care for residents properly. The assessment process involves the resident along with other people and professionals who know about the resident’s likes, dislikes and their history. Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate Staff help people living at the home to be independent and to make decisions about how to live their lives. Mostly care planning is good but some arrangements are incomplete and this means that some needs will not be fully met by the home. EVIDENCE: The home makes sure that they write an individual care plan for every resident. The plans are based on assessment information that the home collects themselves, from the family of the resident and also other health professionals. The Plan is made available in a format that the resident can understand and two residents said that they had their own copy of the plan. All residents have an allocated key worker who has training to make sure they can communicate with the resident. Two residents said that they knew which staff was their special worker and that if they wanted to talk about their plans Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 10 they could speak to any staff on duty and didn’t have to wait till their key worker was at the home. Three care plans were looked at in detail. Mostly the care plans looked at covered all aspects of the residents’ personal, social support and healthcare needs. But some information, which should have been in a care plan had been missed out and this meant that the resident might not have been given all the care and help that they needed. Staff make sure that residents have information, assistance and any communication support that they need to make decisions about their own lives. The staff could show how they make sure that residents who have limited communication are able to make choices about how to live their lives. The home helps residents to take responsible risks. To do this they make sure they have good information on which to base decisions. Any decisions affecting residents’ lives are based on written risk assessment which looks at the residents’ life and social situations. Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,16,16 and 17 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good Residents living at the home are supported to keep contact with people who are important to them and they are helped to participate in fulfilling activities and to be an active part of the local community. Daily routine and house rules encourage personal independence, individual choice and freedom of movement for residents. EVIDENCE: Shopping and leisure facilities are accessible locally in Acocks Green and Solihull. There is good access to public transport links so that residents can get out and about quite easily. The home makes sure that they are aware of what is going on locally and what local resources are offered by specialist organisations. Staff help residents to integration into community life through supporting the use of local services (e.g. shops, library, cinema, pubs, leisure centres). Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 12 Residents are supported to follow new interests, or to continue activities that they enjoyed before moving into the home. One resident said that he is so busy ‘I haven’t got time for anything else’. To help residents with different needs lead a more independent life, where necessary the home makes sure that they seek resources and help from external agencies that have special skills or knowledge to help the resident. Residents are helped to find out about and to take up opportunities for further education. They are also active within the local community and said that they feel part of where they are living. They also say that they are very busy and were seen being supported by staff to go out on trips. Two residents said that they were not often at home and were usually out and about. Records show residents are helped to be politically active and to vote. Information to help residents understand the voting process was also available in alternative formats that the resident could understand. Family and friends are welcome at the home, and with resident’s agreement their involvement in daily routines and activities is encouraged, Family and friends were invited to festivities over Christmas and two residents said that they can invite their friends to the home and if they want to, they can see visitors in private in their rooms. Other people who do not live at the home sometimes restrict residents’ choice. To help protect and promote everyone’s right to make choices about how they want live their lives the home is seeking special advice from outside agencies who know the law and about how to protect the right to make choices. Privacy is important in the home and staff knock on doors before entering bedrooms and bathrooms and residents said that they could be private when they wanted to be alone. There is a lockable drawer in all bedrooms so that residents can keep their belongings safe and they can also have a key to the door so they can secure their room if they choose to. The front door of the house has a code-operated keypad exit facility and currently residents do not know the code. This is clearly assessed within care plans and residents spoken to say that they were happy with the arrangements for going out. There was lots of lively banter between staff and residents showing spontaneity and genuine warmth towards each other. Once a week all residents have a ‘home day’ when staff help them to clean and tidy their bedroom and to do their laundry. This is clearly shown on activity planners and in individual daily diaries and two residents said that they don’t have to do these tasks if they don’t want to. Residents are offered a choice of suitable menus. Records show meals are offered three times a day and residents said that they could have drinks and Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 13 snacks any time they want and that there is no restriction on them entering or being in the kitchen. Records also show residents help to plan and prepare meals so that most times people get to eat what they like. To make sure the home knows how to car for people individual nutritional needs, likes and dislikes were clearly assessed before and after admission. An evening meal was observed. The mealtime was relaxed, unrushed, and had been timed to make sure the evening activities would not be delayed. Dinner was a very pleasant social affair with staff and residents eating together. Food served was well prepared, the portion size was good and residents ate heartily. Two residents said that the food was always good. Where residents needed assistance to eat, staff were seen to help in an appropriate way. This made sure the resident has an unhurried and dignified eating experience and maintains choice of when, where and what the resident wants to eat. Patricia House DS0000070434.V356397.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate The home provides residents with sensitive and flexible personal support that ensures the residents privacy, dignity, independence and control over their lives. Healthcare needs are assessed and recognised but arrangements to address identified needs are incomplete which means that some residents may not get the help and assistance that they need. EVIDENCE: Care plans clearly show how residents personal care was to be given and staff were able to show that they knew and understood this. Personal care and support is given in private. Times for getting up and going to bed, baths, meals and other activities are flexible (including evening and weekends). Residents choose their own clothes, hairstyle and makeup and their appearance reflects their personality. Where there are different communication needs the staff were very able to show how they would make sure residents were given a choice of what to wear. As much as possible residents make decisions about their own healthcare and medical treatment and records show they are supported to access healthcare Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 15 facilities in the local community. In reviewed files there was a healthcare plan for each resident. Mostly the healthcare plans had all the information necessary to help support and promote the resident’s good health. But there was one plan that had important information missing. This meant that a resident might not have got all the healthcare support that they needed. To make sure staff know how to go about giving medication there is clear written medication management policy and procedure. Only senior staff who have completed training give out medication. Recently the right procedure was not followed and medication was not given as it should have been. The medication mistake was identified immediately and the home took prompt and correct action to ensure that no ill effect resulted for the resident. On checking the homes arrangements for medication it was clear that there were some other instances when policy and procedure had not been followed. It was not clear if there had been a recording mistake or if medication had not been given as the prescribing doctor intended. This was discussed with management during the visit and action was taken straight away to make sure residents get their medication at the right time. Patricia House DS0000070434.V356397.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate Residents living at the home are listened to and know how to make their opinions known and who to complain to if they are unhappy. The home has good policy and procedural guidance about protecting adults but practical arrangements are incomplete and could result in incidents which could possibly be abuse not being referred to external agencies for thorough investigation. EVIDENCE: The home has a clear and effective complaints procedure that includes the stages and time scales for the process. Information about how to complain is given to families and residents and is also available in formats suited to different communication needs. There were no records of any complaint to the home and we have not had any made direct to us. Staff know about the complaints procedure and two residents said they knew who and how to make complaints but state that they have nothing to complain about. Answers on surveys show that families are aware of the complaints system. Complaint information is available in alternative formats consistent to understanding and management state plans are in place to develop an audio version. Records within files show that information about complaints is given to residents as part of the assessment and admission process. The hoe has a good policy and procedure for staff guidance on protecting residents form risk of abuse. Records show staff go through basic adult Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 17 safeguarding training during induction and the home have arranged for expanded training for all staff in January. There was one record that had information which should have been referred under safeguarding arrangements to the social services for their decision about how the matter was to be investigated. The home did not identify the safeguarding concern and did not refer the matter to social services. They did say that they had taken some action in response to the information. But there were no written records (in daily diary, handover, or accident records) to show what action had been taken. Arrangements for looking after residents’ finances are good and there are clear systems for keeping residents money safe. All financial records that were looked at showed that the home manages residents’ finances properly. Patricia House DS0000070434.V356397.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good Residents live in a clean comfortable home that meets their physical needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Patricia House is safe, comfortable, bright, cheerful, airy, and clean and is a pleasant place to be. The home is close to local amenities in Acocks Green and Solihull and residents say that it is easy to get about on local transport. The home is over three floors and does not stand out as a care home from the road because it looks the same as other houses near to it. Only the ground floor of the home is easily accessible to residents with impaired mobility or who use wheelchairs. At the time of this fieldwork visit work was nearing completion that will make the garden area fully accessible to wheelchair users. Furnishings, fittings, adaptations and equipment are good quality, domestic, unobtrusive and ordinary but suited to the homes purpose and function and Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 19 meet the needs of people living there. There are three bedrooms to the first floor and two on the ground floor. All bedrooms were personalised by the resident and were well fitted with furniture and equipment the resident needs to help them live independent lives. All residents have well appointed wet rooms accessed through their bedrooms that are for their own private use. If residents want to bath instead of a shower there is also a shared bathroom with a shower over the bath on the first floor. Residents can make private telephone calls whenever they want on a payphone in the entrance corridor to the side of the communal downstairs toilet. Certificates were available to show that the home is safe for residents to live in. Overall the home is pleasantly decorated, the communal areas are pleasantly furnished and fixtures and fittings are well appointed. There is a plan for refurbishment and redecoration and there is an on call maintenance personnel so that the home can be well maintained and repairs can be done quickly. Residents said that they liked the home and that they were able to change or redecorate their bedroom if they wanted to. Patricia House DS0000070434.V356397.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good Residents are supported and protected by the homes recruitment practices and staff are adequately trained to deliver care that meets residents individual needs. EVIDENCE: The home makes sure that all staff working at the home go through a thorough recruitment procedure and records and checks were seen on all reviewed staff files. This helps to ensure the protection of residents living at the home. The home has a written training and development plan identifying relevant training staff need to complete to make sure that they can care for people living at the home properly. Records showed that staff complete a structured induction training program within six weeks of starting to work at the home. The home has only been open since September but records also showed that staff were likely to complete their full foundation training within six months of employment. Patricia House DS0000070434.V356397.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate Overall residents live in a well run home that provides physical safety and where the care they receive is monitored and adapted in light of information about how the home is operating. A number of areas need improvement to ensure that residents total well-being is promoted and protected. EVIDENCE: The registered manager is well qualified and has experience in running similar homes so residents living at Patricia house benefit from a well run home. There is a quality assurance system that is operated and managed by the homes external consultant and aims to ensure the effective operation of the home for the benefit of people living there. There were some variations between the findings of the provider monitoring visits and those of this fieldwork visit. The manager should also have picked up the same issues Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 22 when she was monitoring the home but overall the home is well run and managed by her. The manager said that it was planned that on a yearly basis that surveys and questionnaires would be completed and the results from the quality assurance exercise would be drawn together and made available to interested parties so that they can see that the home is constantly monitoring and trying to improve the care and service delivery to residents living at Patricia House. With some minor exceptions (fire safety records showed two gaps in fire alarm testing, some out of date foodstuffs in the fridge and a risk assessment needed completing) the home makes sure that people at the home are in a safe physical environment. Staff have good understanding of fire precautions, available equipment, fire escape routes and the procedures to be adopted in the event of a fire alarm being raised. Special arrangements had been made for residents who were particularly troubled by fire alarm tests. Patricia House DS0000070434.V356397.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 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 2 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 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x x 2 x Patricia House DS0000070434.V356397.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 17(1)(a) Sched 3(3(i) Requirement The home must maintain an accurate record of all medicines kept in the care home for the service user, and the date on which they were administered to the service user. Timescale for action 25/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 YA19 Good Practice Recommendations The home should consider reformatting resident care plans to make them easier for people to read and to help ensure that all presenting need identified at assessment has a care plan for care delivery to meet the need. The home should seek guidance under MCA to ensure that decisions made by others on behalf of residents do not prevent or impair a residents right to free choice and to exert self-determination. The home should regularly update and check that staffs knowledge and understanding of referring and recognising safeguarding concerns are consistent and that this meets with local safeguarding guidelines and protocols. The home should ensure that quality assurance measures DS0000070434.V356397.R01.S.doc Version 5.2 Page 25 2 YA15 YA16 3 YA23 4 YA39 Patricia House 5 YA42 cover all records and that the manager also monitors delegated duties to ensure these are carried out properly. The home should improve stock rotation and storage of food to ensure that out of date foodstuffs are not kept in the fridge. Patricia House DS0000070434.V356397.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Patricia House DS0000070434.V356397.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. 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