Inspection on 03/12/07 for SCIC - 62 Station Road

This inspection was carried out on 3rd December 2007.

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

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

Other inspections for this house

SCIC - 62 Station Road 15/01/07

SCIC - 62 Station Road 17/01/06

SCIC - 62 Station Road 06/09/05

SCIC - 62 Station Road 14/02/05

SCIC - 62 Station Road 28/09/04

SCIC - 62 Station Road 18/03/04

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 SCIC - Station Road, 62 62 Station Road Studley Warwickshire B80 7JS Lead Inspector Martin Brown Key Unannounced Inspection 3rd December 2007 11am SCIC - Station Road, 62 DS0000004444.V353067.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 SCIC - Station Road, 62 DS0000004444.V353067.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. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service SCIC - Station Road, 62 Address 62 Station Road Studley Warwickshire B80 7JS 01527 857477 01789 296724 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) Stratford & District Mencap Hayley Jane Hemmings Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1) of places SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th January 2007 Brief Description of the Service: 62 Station Road, which was previously also known as The Maltings, provides residential accommodation for eight adults with learning difficulties. It is part of the Studley Project, which is run by Stratford Care in the Community (Stratford and District Mencap). 62 Station Road is a detached purpose built home, situated about a mile form the village centre of Studley. There is good access to local transport and local community facilities. On the ground floor, there is a large lounge, a dining room, laundry room, one bedroom with en suite facilities and a kitchen. On the first floor there are a further seven single bedrooms for service users, a shower room, bathroom, two toilets and a room used by staff as an office and sleeping in room. There are six residents currently all are men. There is a garden to the rear, which has ramped access, laid to lawn with barbecue area and patio. The manager advised that fees are currently £610.13 per person per week, and that all placements are currently funded by Warwickshire County Council. Hairdressing, toiletries, and holidays are extra. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report has been made using evidence that has been gathered by the Commission for Social Care Inspection. The inspection visit was unannounced and took place on 3rd December 2007. The inspection started at 11am and lasted for six hours. All residents seen and spoken with over the course of the inspection, as were staff on both the morning and afternoon shifts. A tour of the premises was made, relevant documentation was looked at, and observations of the interactions between residents, staff and their environment were made. Policies and procedures, and care records were examined, and three residents were ‘case tracked’, that is, their experience of the service provided by the home was looked at in detail. Specific elements of other residents’ care were also looked at in detail. Additional telephone contacts to three relatives of service users were made following the inspection. The Annual Quality Assurance Assessment, competed by the manager, also informed the inspection in a clear and relevant manner. Staff and residents were welcoming and helpful throughout. What the service does well: What has improved since the last inspection? Financial arrangements for when staff escort service users have improved. Staff have benefited from dementia training, to help meet specific needs. Information for residents is being provided in a more accessible way, with greater use of clear simple printing and use of photographs and pictures. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 6 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. SCIC - Station Road, 62 DS0000004444.V353067.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 SCIC - Station Road, 62 DS0000004444.V353067.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is no reason to doubt that any future admission would be subject to the same thorough assessment and introductory procedures as previous admissions. ‘User friendly’ information concerning the home is good and continuing to improve. EVIDENCE: There have been no new admissions since the last inspection. The most recent admission involved extensive assessment and introductory periods. The manager advised that any future admissions would involve a similar process, and detailed the process in the Annual Quality Assurance Assessment. The home is registered for eight people, although the manager advised that the service acknowledged that the size and nature of the building is such that six is a more realistic number, and agreed that the registration should be amended to six. There is one bedroom that is empty and used for storage, and one that is now the staff room, used as an alternative to the office for sleeping-in purposes. Good, clear, picture contracts were seen for individuals. Service user guides were seen. These had plenty of pictures, to help make them easier to understand, but, as the manager pointed out, could benefit from relevant photographs rather than line drawings, and she intended to revise them to SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 9 make them more specific to the home, rather than to the general local service, as they are at present. SCIC - Station Road, 62 DS0000004444.V353067.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their needs are reflected in individual Plans, and that they are supported in making decisions and taking risks as part of an independent lifestyle. EVIDENCE: A sample of three individual care files were examined. These included personal profiles, care plans and risk assessments, which covered areas relevant to that person, and which are updated at least every six months. These plans are hand written, but are in the process of being transferred to computer to make them more accessible and ‘user friendly’ with photographs and being written from the resident’ perspective (‘I like to do this, I need help to do that,’ etc.) The work done on these so far, and with recently introduced information such as staff pictures, menu details, and suggest that these will be far clearer and much more accessible to people living at the home. The current plans continued to detail needs and how they are supported, and showed up-to-date reviews and detailed specific needs and how they were being met, with specialist support and advice as needed. Staff and management were able to SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 11 discuss needs and challenges presented by specific highlighted residents, and how these had been responded to. Documentation reflecting this was available. The manager was able to give examples of recent support to residents in making choices, from involvement in choosing colours and furniture in preparation for the refurbishment of living areas, to each choosing Christmas decorations on a recent shopping expedition. Risk assessments were seen most frequently as part of general support guidelines, and guided and reflected practiced as observed during the inspection. Residents continue to have their own preferred routines around the home, spending time in their room, checking out what staff are on duty when, checking what is for tea, or spending time watching the television. Risk assessments are in place to meet individual needs. One that impacts on everyone is the need to have the kitchen locked at times when there is no direct staff supervision, owing to the current needs of two residents. The kitchen remained open and accessible throughout the inspection, as there were always staff in the vicinity. A new system of mail folders were being introduced to support service users in having more control over post received. SCIC - Station Road, 62 DS0000004444.V353067.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents continue to have a variety of activities and contacts that they are happy with, and look forward to mealtimes, which offer a balance between good nutrition and personal preferences. Some residents may benefit from more activities, and ones that suit individual needs. EVIDENCE: Two residents were at home on the day of the inspection - one through illness, and one through having a regular day at home. Other residents returned home after attending a regular day service. The manager advised that the residents all attended a day service generally four days a week, with some attending college courses. The manager also advised that they had all attended a variety of day services for many years, and were content with this pattern. Residents spoken with said they liked going to day services, but equally, liked being back home. For those spoken with, the balance between attending a day service and spending time at home appeared to be about right. The manager advised that evening and weekend activities were enjoyed by residents, who liked, in many SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 13 instances, going to clubs and discos. A venue had been booked for after Christmas for residents to host a party/disco for friends and families. Relatives spoken with felt that there were not enough activities at weekends and evenings, and that a reason cited for this was usually insufficient staff. Two relatives felt that individual residents could benefit from more exercise, with one in particular enjoying walks, but rarely getting the opportunity for this activity at Station road. Another felt that, other than attending day services, the opportunities to do things outside the home was very limited. This person also felt that information provided by the home was, at times, patchy, being unaware, on one occasion, when planning to visit, that the resident was on holiday. The manager expressed an awareness of the need to provide more opportunities for activities for individuals, and was planning more social events. One relative commented that, when the day service was closed, residents missed it, indicating a need for the home to provide more activities during these periods. Photographs continued to evidence the variety of activities enjoyed by residents. One resident was pleased to point out himself and family members on photographs. The manager detailed how spiritual needs of individual residents were catered for, attending services in various local venues. A menu folder showed well-illustrated guidelines on individual dietary needs and preferences, giving a clear guide to staff, which would also be meaningful to the individual residents concerned. Staff were aware of individual dietary concerns, and of how these were catered for. Residents who responded to questions regarding food said that they enjoyed the meals. Where there are dietary issues, appropriate professional support has been sought. One resident for whom diet and eating sufficiently had previously been a difficulty, was now noted as having a much more substantial and healthy diet. . SCIC - Station Road, 62 DS0000004444.V353067.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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal support needs are met by the service, although they may benefit more by the manager ensuring that all staff consistently follow good practice in respect of personal dignity and privacy. Residents can be confident that the manager is promptly addressing identified shortfalls in medication administration and recording. EVIDENCE: Records were seen of regular health checks, and of consulting with relevant professionals and in managing particular health and support issues. A variety of issues concerning the well-being of individual residents were being addressed, with appropriate support, and with progress noted. The manager was seen to demonstrate and promote warm positive interactions with people living in the home, providing prompt support and reassurance to individuals. One incident, where a staff member was assisting a resident to change clothes in his room, while the door and curtains were both open, was promptly addressed by the manager. Additionally, when one resident started to undress in a communal area, he was swiftly but gently encouraged by the manager to move to a more appropriate area. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 15 Medication records were examined. The majority of medication is dispensed by ‘blister pack’ and these were correctly dispensed and recorded. Some medication cannot be dispensed in this manner. Records showed that one medication had not been recorded as dispensed from two days previous, and that there were consequently two tablets of this medication outstanding. There was no daily stock control of this medication to confirm that the omission was on this date, and the manager agreed that it was alarming that the omission, and the consequent additional two tablets, had apparently not been noted or acted upon by the following two staff administering medication. The manager acted promptly by introducing a stock control chart for ‘non-blistered’ medication, and said she would investigate the events concerning this mistake, introducing any ‘refresher’ training as needed. All other records were seen to be accurate and properly recorded. Photographs or residents were in place, as were details of the reasons for medication. Additionally, information sheets provided in medication were retained in case they needed to be referred to in the future. This information informed the dietary need of one resident to avoid grapefruit or grapefruit juice. General medical information concerning individuals was also provided in this folder. Those looked at were not dated. The manager agreed that these should be dated to facilitate reviews and ensure the information remained up-to-date. Relevant regular recordings of urine tests for one person were in place. The manager agreed that it may be useful for staff undertaking these to sign the recording made. SCIC - Station Road, 62 DS0000004444.V353067.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the service continues to work to protect service users from abuse, selfharm and neglect, and to listen to and act on their views. EVIDENCE: The complaints log was seen. This contained one complaint. This involved an incident where one resident had hit another. The manager had supported the victim in having this noted as a complaint, and it formed part of a strategy of managing unacceptable behaviour by the other resident, as well as assuring the complainant that his concerns were heeded and actioned. There have been no concerns received by Commission for Social Care Inspection concerning this service. Relatives spoken with were all complimentary about the service. Staff spoken with showed a good understanding of abuse and how to report any allegations. A sample of personal finances looked after for individuals by the service were looked at. These were recorded clearly and accurately, with receipts available for all relevant purchases. The manager agreed that receipts should be numbered for easier reference, and advised that this would be done. Monies are checked daily by the person responsible for that shift, with random checks by the manager, and yearly audits by the finance director of the organisation. There is no longer an expectation that service users or staff should pay for staff costs incurred on, say, a cup of coffee whilst out on a social skills or similar trip with a resident. Instead, any such expenditure will be approved by the manager if it is agreed that it is reasonable and equitable. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 17 SCIC - Station Road, 62 DS0000004444.V353067.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): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well-maintained home, but could benefit further if it was refurbished, with particular emphasis on making it lighter and brighter. EVIDENCE: The small garden area at the front of the house is now much more attractive with the planting of low maintenance bushes and plants. The rear garden was well-maintained. The home is well-maintained, but, as the manager pointed out, is a little ‘tired’ and could benefit from refurbishment. Chairs in the lounge are to be replaced, and refurbishment of the kitchen is planned. The freezer that was previously inappropriately placed in the laundry has now been moved into the kitchen. The hatch from the kitchen to the dining room is used. When this hatch is open, there is a risk of someone banging their head on it if it is not flush against the wall. The manager agreed that would be safer if it could be secured to the wall when open. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 19 For a relatively modern building, the whole house suffers from relatively small windows, and an excess of corridor. In effort to make the home appear lighter and brighter, the manager hopes to have all window frames, doors, wall coverings and curtains in lighter shades. Ensuring sufficient light levels is particularly important where there are people with mobility difficulties, and dementia diagnoses. A discussion was had with the manager as to whether all the wall upstairs by the stair was, in fact, necessary, as they made the corridors even more lengthy. Walls in communal areas are given interest by pictures, some of them by residents. Bathrooms and toilet areas were clean, tidy and hygienic, as was the laundry room. The home was clean and largely free from offensive odours, although there was a faint odour in one bedroom, where there is a recorded problem with incontinence. This was now being better managed than previously, with new flooring, and a consequently much fainter odour. Bedrooms are lockable, although the manager advised that few people chose to lock their rooms. One bedroom, with en suite facilities, was seen. This had been personalised with items reflecting the interests of the person concerned. Some doors had ‘fire door – keep shut’ or even ‘keep locked’ notices on, although they appeared not to be fire doors. The manager advised that she would review these, and only retain necessary notices. The front door has an alarm buzzer on it, to alert staff to its use. SCIC - Station Road, 62 DS0000004444.V353067.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): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from the attentions of a consistent staff team who have worked at the home for a number of years, with whom they are familiar with, and who are familiar with their needs. Residents’ privacy and dignity may be compromised if staff do not support and encourage them in maintaining this. Residents’ access to individual activities may be restricted by there being insufficient staff to support these. EVIDENCE: There were two staff on duty in the morning and the evening shift, with the manager also present in the day, so that there were always two staff available. The manager advised that she did a number of ‘duty’ shifts. Pictures of staff on the wall helped residents who wished to identify staff who were to be on duty. A sample of staff files were looked at. The staff team is very consistent, many of them having worked at the home for many years, with the ‘newest’ staff having been in post around two years. Consequently, residents were familiar with and comfortable with staff, although some staff also work at other services provided by the organisation. Staff spoken with were knowledgeable on matters such as fire safety and abuse, and were familiar with particular needs of service users and how to meet them. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 21 Individual training records, and a training matrix showed staff training needs being met in specialist areas, as well as statutory ones. One staff member is now an assessor for the new Learning Disability Qualification. While observed practice was generally good, with the manager demonstrating a strong lead on this, it was noted that one staff neglected to encourage one person in valuing privacy and dignity by helping him undress in a lighted room without closing the door or the curtains. Although the manager promptly rectified this, it demonstrated the need for either refresher training, or at the least, reminders at staff meetings, or supervisions, of the need to encourage and support notions of personal dignity and privacy. Recruitment files looked at demonstrated appropriate procedures, with references, proof of identities, and written references being obtained. However, there were no proofs of Criminal Records Bureau checks available. These has previously been seen, but the new manager could not locate them. She was able to confirm by telephone the following that the organisation’s personnel department had a list of all staff numbers and confirmations and was forwarding a copy to her. Relatives had commented about a lack of activities for residents at weekends and in the evening, and queried whether more staff, or more flexible deployment of staff, would enable there to be more opportunities for residents. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an enthusiastic manager who is keen to extend residents’ choices and opportunities. They can be confident that the manager is aware that quality assurance needs to reflect more directly their experience, and is working to ensure this. Residents’ health, safety and well-being continue to be protected and promoted. EVIDENCE: A new manager has been in post for six months and has been working particularly hard in making information more accessible for residents. She showed a good awareness of care standards and how to meet them, and a commitment to giving residents choices and making these choices understandable to them. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 23 The manager was witnessed leading with good practice and promptly correcting poor practice. Staff and relatives were complimentary about the manager, staff commented how she is giving them more responsibility, and relatives commented that approachability and enthusiasm to improve things for residents. The service has a quality assurance process, into which information from the home is goes, using ‘user friendly’ questionnaires. Perhaps more immediately relevant to residents are regular service users meetings, which are supplemented by individual discussion with residents who may not be as forthcoming in group meetings. Issues raised by relatives, and by staff and management, such as how some residents in particular would benefit from going out more, did not appear as clearly highlighted themes on quality assurance documents. These are difficult issues for the residents at Station Road to articulate without support, and none of them were able to give clear responses, (other than, for example, ‘like snooker’) when asked about them during this inspection. The manager showed awareness of this, noting that obtaining service user feedback in more suitable forms was an area for improvement in the Annual Quality Assurance Assessment. Regular ‘Regulation 26’ visits from the registered provider or their representative take place. Fire and other safety checks were in place, staff showed a good awareness of fire procedures, and the most recent fire inspection noted the home as satisfactory. The Annual Quality Assurance Assessment returned by the manager detailed safety checks and procedures as being in place. There were no hazards noted during a tour of the premises, with potentially hazardous substances being locked away. SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The service must ensure that all ‘non blistered’ medication is accurately stock controlled, and that any error on administration or recording is acted upon in a timely manner. Timescale for action 05/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA3 YA14 Good Practice Recommendations Reducing its registration from eight persons to six would reflect the service offered more accurately. The service should support individual residents to take part in activities such as walking and attending social events more frequently. The service should ensure all relatives are kept informed of activities involving specific residents. Refresher training for staff in respect of supporting residents to maintain personal dignity and privacy would DS0000004444.V353067.R01.S.doc Version 5.2 Page 26 3. 4. YA15 YA18 YA35 SCIC - Station Road, 62 help ensure consistent good practice in this area. 5. YA20 Recording of the results of any regular testing, such as urine testing for diabetes, should be initialled or signed by staff. Any information regarding medical or medication matters should be dated to facilitate regular reviewing and ensuring it is up to date. Receipts of expenditure by residents should be numbered to make retrieval and referral easier and clearer. Any redecoration and refurbishment should take account of the need to make the interior of the home brighter and lighter. Only necessary fire door notices should be retained, to avoid misinformation, and avoid making the home appear institutional. Being able to secure the kitchen/dining room hatch door when open would reduce any risk of injury. 6. YA20 7. 8. YA23 YA24 9. YA24 10. YA24 SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 27 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 SCIC - Station Road, 62 DS0000004444.V353067.R01.S.doc Version 5.2 Page 28 - 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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