Inspection on 22/05/07 for 27 Stratford Road

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

27 Stratford Road 13/05/08

27 Stratford Road 20/12/05

27 Stratford Road 27/07/05

27 Stratford Road 10/03/05

27 Stratford Road 30/10/04

27 Stratford Road 27/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 SCIC - Stratford Road, 27 27 Stratford Road Shipston On Stour Warwickshire CV36 4AZ Lead Inspector Jo Johnson Key Unannounced Inspection 22nd May 2007 2.30pm SCIC - Stratford Road, 27 DS0000004445.V340224.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 - Stratford Road, 27 DS0000004445.V340224.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 - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service SCIC - Stratford Road, 27 Address 27 Stratford Road Shipston On Stour Warwickshire CV36 4AZ 01608 663129 01789 296724 david@stratfordmencap.org.uk 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 Ms Julia Furniss Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (2) of places SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: 27 Stratford Road is a registered care home for 5 adults who have learning disabilities. Stratford and District Mencap provide 24-hour support and care for the people living in the home. The house is located on a main road close to the town centre of Shipston on Stour where a wide range of community facilities is available. There is a bus service from Oxford to Stratford with a bus stop directly in front of the house. 27 Stratford Road is a detached house built in the 1930s. It has been converted to provide five bedrooms for service users. There are two bedrooms on the ground floor and four bedrooms on the first floor, one of which is for staff doing sleep-in duties. There is also an office and bathroom with toilet on the first floor. There is access to a large loft area but for safety reasons this is not in general use. Shared facilities on the ground floor consist of a dining room, lounge, large kitchen, utility area, a shower room (which is wheelchair accessible), and a separate toilet facility. There are secluded gardens to the rear of the property, with wheelchair access. The fees for the home are £610.13 per week. People are charged extra for some items, including, clothing and toiletries, activities, holidays, private chiropody, leisure transport. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Before the inspection visit, the manager had forwarded to the Commission a pre-inspection questionnaire, a staffing rota, training records and menu records for the home. All pre-requested documentation returned was examined as part of the inspection process and the evaluation included in this report. Questionnaires were not sent out to people living at the home or their relatives. The views of the funding local authority were sought and have been included in this report. The inspection visit was unannounced and took place on Tuesday 22nd May at 2.30pm until 7.30pm. Further discussion with the manager took place the following day by telephone. The inspection involved: • • • Discussions with the five people who live at the home and the carer and manager on duty at the time. Observation of working practices and of the interaction between individuals and staff. Two people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • I would like to thank the people who live at the home, manager and staff for their hospitality and cooperation during the inspection visit. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 7 There is not anything that the home must do better to meet regulations. However, there are some good practice recommendations for areas that they should improve on. 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 - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good People’s needs are assessed and they are provided with information so that they are clear about their rights and entitlements at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide are in large print and supported by pictures, which makes it easier for people with learning disabilities to understand the services in the home. Two of the people went through the document and said that it was easy to follow. One person said that they could read it without the pictures but added, “the pictures are good, I like them”. There have been no new people admitted to the home for a long time so the outcomes for any new person coming to live in the home could not be assessed. However, there are ongoing and regularly updated assessments in people’s care records that have been amended as their needs have changed so that staff have up to date information about them. SCIC - Stratford Road, 27 DS0000004445.V340224.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. The people living in this home are involved in decisions about their lives and are playing an active role in planning their care and the support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people’s care records were seen. The care plans and risk assessments had recently been reviewed and included all the care and support they need. People’s assessments and care plans had been reviewed on a six monthly basis but had also been amended as and when people’s needs have changed. This is particularly important, as the people living at the home are growing older and have increased and frequently changing health and personal care needs. All of the people living at the home said that staff ask them what help and support they need and that they make decisions about their daily lives. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 11 There are good descriptions in people’s care plans of how staff are to support people to make choices and decisions and promote their independence in their every day lives. People have signed their care plans and risk assessments to show that they have agreed and understand them. One person said, “staff go through things with me…they tell me what they’ve written”. Another person was very proud of their new pictorial care plan routine that was in their bedroom. They said “look at this, it’s so I know what I need to do each day… staff write in my diary so I know what I’ve been doing”. The manager and staff should continue to develop people’s plans supported by both photographs and pictures. This is so that all parts of peoples’ records are accessible and easier for them to understand if they do not read. Risk assessments were in place for each person that were regularly reviewed as part of the care plan reviews and as new or changed risks were identified. They were clear and easy to follow. Each person has an ongoing ‘life story’ book. These books have photographs and items in them that show what the person has been doing. One person went through their book and seemed to have fun remembering things they had done on the past and naming people in the photographs. However, due to staffing difficulties over the last year these are not up to date. Staff should make sure that they keep ‘life story’ books up to date, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. As people living at the home are ageing, it is important that ‘life history’ books are also developed that includes details and photographs of their ‘history’ such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. SCIC - Stratford Road, 27 DS0000004445.V340224.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): 12,13,15,16 and 17 Quality in this outcome area is excellent The people living in this home are supported to make choices about their lifestyle and to develop life skills. Daily activities promote independence and opportunity for people to live ordinary and meaningful lives in the community where they are living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the start of the visit, two people were at home and the atmosphere was relaxed and welcoming. The three other people returned later from their community activities. Most of the people living at the home attend day community services or work for part of the week and spend at least one day at home to carry out light domestic chores, such as cleaning, laundry and shopping. Two of the people SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 13 access local community older people’s day centres. All of the people spoken with were enthusiastic about how they spend their days both in the community and at home. Some comments were “I’ve had a day out with my key worker, we bought clothes and a razor”, “we choose what we want to eat on a Sunday…if we want different things I go to the shops” and “I’ve been to … today, we made cakes and wished a lady happy birthday”. During the visit, people living at the home were talking about their annual holiday. Four of them have chosen to go together and one person is going on their own. The person going on their own said “I went to … last year on my own, I like going on my own with staff”. This is very positive that people are supported to spend their leisure time either on their own or with others that they live with. Daily records looked at showed that during the week activities to meet identified needs are regular and support ordinary and meaningful lifestyles. There is significant evidence on care plans and in photographs displayed around the home that people’s activities are wide and varied and meeting their needs regarding maintaining family links and cultural needs. The menus show that people are provided with a well-balanced and nutritious diet. All food being stored in the kitchen looked fresh. As evening mealtime approached, people were involved in the food preparation and laid the table. People go food shopping with staff support if they want to. Everyone said that they enjoyed the food provided by the home. Specialist diets are catered for and staff have recently had training on diabetes. SCIC - Stratford Road, 27 DS0000004445.V340224.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 and 21 Quality in this outcome area is good The health and personal care that people in this home receive is based on their individual needs. Staff respect the people and promote their dignity and privacy. Medicine recording systems could be improved upon so that the records reflect the good practice of promoting people’s independence in managing their own medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between staff and the people who live at the home. People commented that they know, get on well with the staff and they treat them well. One person said “ we have the same staff…the new ones know us now” and another said “they are nice when they help me with a wash”. People’s health records and care plans showed that their right to good-quality physical and mental health care is being promoted. The records show that as SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 15 part of promoting their health people make regular visits to a dentist, optician, specific health consultants, their GP and a chiropodist when needed. People’s weight is recorded and monitored in the interests of maintaining good health. However, this is kept on communal record with a code used to represent each person. All information relating to an individual should be kept on his or her own records. Personal health information (even if coded) should not be kept on communal records. This is because this information is only relevant to that person and must not be shared with other people who may request to see the information. Staff are trained in the medication policies and procedures during induction and there is a medication training programme. The manager has recently introduced a medication refresher/competency assessment to make sure staff continue to administer medication safely. Medication records seen were correct and the manager and staff actively monitor the completion of the medication records. Two of the people living at the home are supported to manage their own medication by means of using an easy to use daily dossette box. There are risk assessments in place that acknowledge and minimise the risks of staff making up these dossette boxes. However, the current practice of recording that staff are actually administering the medication to the person on daily basis is not safe, as this is not what they are doing. The manager should ensure that a medication plan is developed and a record kept that accurately reflects the current practice. This will acknowledge that whilst the current arrangement does not meet the royal pharmaceutical guidelines for medication management in care homes it does promote and maintain the independence of these two people. The manager and staff are proactive at meeting the specific social, health and personal care needs of the people who are ageing at the home. A care plan document has been devised, in pictorial and large print format to record the wishes of people in the event of their death. These had been completed people living at the home and were kept in their care plan file. SCIC - Stratford Road, 27 DS0000004445.V340224.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 excellent The people who live in this home are able to express their concerns and know whom to speak to if they are unhappy or feel unsafe. They are supported by a staff team who have a good knowledge of how to respond to any suspicion of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection about the home since the last inspection. In the pre- inspection questionnaire the manager reports that there have been 4 complaints made at the home. Following discussion with the manager, these complaints were concerns from the people living at the home that were addressed as soon as they were raised. It is good practice that these day-to-day concerns are recorded on the complaints log, as it shows that people’s issues and concerns are taken seriously and addressed as soon as they are raised. Service users said they felt safe and would know whom to talk to if they were unhappy. Service users have access to a complaints policy, which is in symbol and large print format and includes information about the Commission for Social Care Inspection. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 17 All of the people had a pictorial guide on how to keep safe and what things they need to report to staff. They all were able to explain that they felt safe and knew that they needed to talk to the manager or staff if they were worried about anything. This is excellent practice. Staff spoken with confirmed that they had been provided with prevention of abuse training at various times. They said that Whistle blowing and Protection of Vulnerable Adult information is included in their induction training. An adult protection procedure is in place at the home to inform staff of the appropriate measures to take to report any suspicions of abuse and this includes information for staff on the managers contact details. SCIC - Stratford Road, 27 DS0000004445.V340224.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 The home is well maintained and furnished so that people live in a clean, comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit, it was homely, comfortable and safe. People living there were able to move around easily and freely and to go to their bedrooms if they chose. One of the people proudly gave a tour of the communal areas of the house and their bedroom. The home was clean and free from any offensive odours. All of the people living in the home were happy to show their bedrooms. The bedrooms reflected their individual lifestyles, interests and tastes. One person said, “ I like to come in here and relax” another said “I’ve got all my things in here…it’s a private space”. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 19 People at the home said that they are involved in cleaning and tidying alongside staff. They said that the staff help them with their laundry. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Infection control training is included in mandatory training for all staff. As mentioned throughout the report there is an ageing group of people living at the home, some of who are becoming increasing frail. The manager and staff group are very proactive at ensuring their social; health and personal care needs are met. However, The manager should start to plan for some of the changes that might be needed to the environment as people become increasingly frail. This is so the people can continue to live safely and as independently as possible in their home. SCIC - Stratford Road, 27 DS0000004445.V340224.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): 32,33, 34 and 35 Quality in this outcome area is excellent The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of care practice and discussion with the manager and staff member on duty at the time showed that positive relationships exist between the people and the staff supporting them. People living at the home sought staff out and were comfortable with them. The staff seen were good listeners and communicators and were interested and committed to the work they were doing. A member of staff spoken with felt they had the skills and experience necessary for the tasks they were expected to do and this included Learning Disability Award Framework training and NVQ. The home has a very low turnover of staff with only two staff leaving since the last inspection. Staff sickness levels are also very low and this means that a SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 21 consistent staff team that they know well supports the people living at the home. The manager said that since the last inspection new staff have been recruited to replace the staff that have left and staff who had been on maternity leave. One person said “the new staff are ok…they are getting used to us all”. Pre-inspection information and the training chart in the home shows that staff have accessed training in the full range of mandatory, health and safety related training, (e.g. first aid, food hygiene and fire safety) as well as specialist care courses, such as dementia, diabetes, epilepsy and death, dying and bereavement. The training programme includes Equality and Diversity training. However, to date no staff have attended this training. The manager said that now that the home is fully staffed again, staff would be booked on this training. The two most recently recruited staff files were seen and they included all of the necessary documentation to demonstrate that the staff are suitable to work with people living at the home. They all included CRB (Criminal Records Bureau) checks and three references. Obtaining three references is excellent practice and exceeds both the National Minimum Standards and the Care Homes Regulations. Staff spoken with said they had regular supervision and staff meetings. Discussion with staff and examination of the staffing rota shows that there continues to be good levels of staff support for the people living in the home. People living at the home said they know all of the staff and who is working each day. There is a weekly photographic rota on display on the kitchen. This is good practice. SCIC - Stratford Road, 27 DS0000004445.V340224.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 People continue to benefit from living in a well run home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has approximately 17 years experience of working with people with learning difficulties including 9 years as a manager. The manager also holds the Registered Managers Award and National Vocational Qualification, level 4 in Care and is well qualified for the role as Care Home manager. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 23 From discussion with people living at the home, staff, the manager, the examination of records and observation of care practices show that a competent and skilled manager runs the service. Last year the people living at the home were surveyed for their views. The outcomes of this consultation were summarised and fed into the development plan for the home. The manager said that she intends to give out fresh questionnaires for people to complete again very shortly. People said that they have regular house meetings where they can say what they want about the running of the home. An employee of the organisation is carrying out monthly monitoring visits and copies of the reports were seen at the home. The reports show that suitable arrangements are in place for monitoring the work of the home and provide an opportunity for the visitor to seek the views of people using the service and to check significant records, such as accidents, incidents and complaints. Staff carry out regular Health and Safety audit and reports are held at the home. Any shortfalls that are identified are brought to the attention of the manager to address, e.g. repairs to equipment. Information provided by the manager in the pre inspection questionnaire indicates that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. Risk assessments have been completed for safe working practices and these are reviewed regularly. Risks from hot water in people’s bedrooms have now been assessed. SCIC - Stratford Road, 27 DS0000004445.V340224.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 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 4 33 3 34 4 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 3 16 x 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 4 3 x 3 x x 3 x SCIC - Stratford Road, 27 DS0000004445.V340224.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. Standard Regulation Requirement Timescale for action 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 YA7 Good Practice Recommendations People’s plans should continue to be developed and supported by both photographs and pictures. This is so that all parts of peoples’ records are accessible and easier for them to understand if they do not read. ‘Life story’ books should be kept up to date, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. ‘Life History’ books should be developed that include details and photographs of their ‘history’ such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. All information relating to an individual should be kept on his or her own records. Personal health information (even if coded) should not be kept on communal records. This is DS0000004445.V340224.R01.S.doc Version 5.2 Page 26 2 YA7 3 YA7 4 YA19 SCIC - Stratford Road, 27 5 YA20 because this information is only relevant to that person and should not be shared with other people who may request to see the information. A medication plan should be developed and a record kept that accurately reflects the current practice. This will acknowledge that whilst the current arrangement does not meet the royal pharmaceutical guidelines for medication management in care homes it does promote and maintain the independence people living at the home. A plan should be developed for some of the changes that might be needed to the environment as people become increasingly frail. This is so the people can continue to live safely and as independently as possible in their home. 6 YA24 SCIC - Stratford Road, 27 DS0000004445.V340224.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 - Stratford Road, 27 DS0000004445.V340224.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!