Inspection on 05/07/06 for Sparrowfields

This inspection was carried out on 5th July 2006.

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

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

Other inspections for this house

Sparrowfields 31/05/07

Sparrowfields 13/12/05

Sparrowfields 01/07/05

Sparrowfields 16/12/04

Sparrowfields 05/08/04

Sparrowfields 03/02/04

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 Sparrowfields 17-19 Alwold Road Weoley Castle Birmingham B29 5RR Lead Inspector Sarah Bennett Unannounced Inspection 05 July 2006 10:00 Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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 Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sparrowfields Address 17-19 Alwold Road Weoley Castle Birmingham B29 5RR 0121 428 2848 0121 428 2849 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) Shaw Healthcare (Specialist Services ) Ltd Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate 6 Service Users with a learning disability aged 18- 65. 13th December 2005 Date of last inspection Brief Description of the Service: Sparrowfields is a purpose built care home. The home accommodates six men, who all have a learning disability, and some additional needs regards challenging behaviour. The home is not suitable for people who have mobility difficulties. The accommodation comprises of a kitchen, laundry room, main lounge with access to the garden, a quiet lounge, and a dining room on the ground floor. On the ground floor are two toilets, for staff and visitors use. On the first floor, are six single bedrooms, all with en suite, a communal bathroom, and a room used by staff for medicines storage. The home has a small garden to the rear, which includes a shelter for smokers. At the front of the home is parking for several cars. The home is located in Weoley Castle, and is close to main transport links. Shopping and leisure facilities are available in Weoley Castle, Northfield and Birmingham would be accessible. The pre-inspection questionnaire completed by the manager states that the fees are £1,700. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a completed pre – inspection questionnaire. One inspector carried out the unannounced fieldwork visit over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. The staff on duty and the Manager were spoken to. The inspector met with five of the service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? Before new service users moved into the home an assessment had been completed to make sure that their needs would be met and they would be supported to achieve their goals. Service users are involved in their care plans so that their views are taken into account and they are supported in the way they want to be. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 6 Service users are asked about what they want to do, what they want to eat and how they want the home to run. Minutes of meetings showed that their views are put into action. Service users said they do go out in the evenings to pubs, for walks and for drives. An audit of all medication that is not kept in the blister packs is done to make sure that it is being given properly. Protocols are in place for medicine that can be given when required so that it is given to the person only when needed and the right dose is given. The adult protection policy had been changed so it is clear to staff at the beginning that the first thing to do is to make sure that service users are safe. New furniture had been bought for the dining room and some rooms had been decorated. This makes the home more comfortable and a nicer place to live. All areas of the home including the kitchen were clean. Service users said that they are supported to do the cleaning which helps them to be more independent. New staff have been recruited to work at the home so that all the staff that work there know the service users well. A Manager had been recruited and they had applied to be registered as required with the CSCI. Staff regularly check the fire equipment to make sure it is working. 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. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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 Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about whether or not they want to live at the home. Prospective service users individual aspirations and needs are assessed and they have an opportunity to visit the home before moving in. Each service user had an individual contract but they do not have the information in the home so it is not clear whether or not they are aware of the terms and conditions of their stay at the home. EVIDENCE: The statement of purpose of the home and the service users guide included all the relevant and required information. The service users guide was produced in a format that was easier to understand making it accessible to the people who live in the home. It stated that it could be produced in other formats if necessary as required by individuals depending on their communication needs. Two service users had been admitted to the home in the last year. An assessment was carried out by their social worker and the home to ensure that the home could meet their needs. Risk assessments and support plans were developed to ensure that it was safe for the individuals to live in the home in the community and they would receive appropriate support. The home has an Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 9 admission procedure that includes the relevant information including assessment of the individual and visits prior to moving in. Before the service users moved to the home they made several visits to meet the other people who lived there and the staff. These included an overnight stay. Records sampled showed that these visits went well. Service users had a placement contract but not a contract with the home stating the terms and conditions of their stay. The Manager said that these are in place but are currently held at Head Office. However, she will arrange for a copy to be put in each person’s individual file. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need to support individual service users to meet their needs and achieve their goals. Service users are supported to make decisions about their lives and are involved in the running of the home. Service users are supported to take risks within a risk assessment framework. EVIDENCE: Two service users records were sampled. Records included an individual care plan that stated what support the person needed from staff to meet their needs and achieve their goals. Care plans were person centred and showed that the individual and the people important to them were involved in developing it. The care plan includes some great things about the person, their preferred lifestyle, their experience of making choices, hopes and dreams, their experiences including their family history, likes and dislikes, health needs, dietary needs and preferences, personal care and self-image, relationships, communication, daily routines, occupational support and the things the person Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 11 wants to learn. Records showed that regular review meetings are held at which the care plans are developed further if needed. Care plans sampled stated what support the person needed to make choices and decisions about their day-to-day lives. Regular group service user meetings are held and minutes of these are kept. These showed that service users talk about what food they want, holidays, decoration of their bedrooms, games, activities and how to make a complaint if they are unhappy with anything in the home. Minutes showed that if a service user wants an individual meeting with staff this happens. The Manager said that the organisations Service User Project Officer visited the previous week. They had asked service users to complete a questionnaire about their involvement in the home. This will provide a baseline from which they can work to ensure that service users are involved in the day-to-day running of the home and the organisation. Records sampled included individual risk assessments. These state how staff are to support individuals to minimise the risks when accessing the community, smoking, money management, visits with relatives where appropriate, when displaying verbal and physical aggression, eating and drinking, sexual relationships, activities such as swimming, football and boxing, travelling in the home’s vehicle or on public transport and self-harm including drug abuse. Risk assessments are reviewed monthly and updated where necessary. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience a meaningful lifestyle that suits their individual needs and preferences. EVIDENCE: One service user went to Northfield on public transport with a member of staff. Daily records sampled showed that service users go to the pub, restaurants, shopping, church, for walks, to the bank, parks, disco, drives, gym, swimming and play football. Service users said that they go out in the evenings to the pub, for walks and for drives. Inside the home service users watch TV and said they had watched the World Cup football matches, listen to music and watch DVD’s. One of the service users is very interested in music and said that they wanted to buy some decks and radio equipment. Staff supported them to ensure they had enough money to buy these and to go and buy them. It was evident that they were enjoying these as they demonstrated them to the inspector. A member of staff was Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 13 supporting them to ensure they used them appropriately and got maximum benefit from them. Staff said that three of the service users were supported to go on holiday to Cornwall for a week in May and two service users had just returned from a week in Blackpool. Staff said that one service user wants to go away to Blackpool later in the year and they are planning this. Service users said that they are supported to visit their family and friends if this is appropriate and their family can visit them. One of the service users made a telephone call to a relative and said that they often do this to keep in contact with them. One of the service users was going away to Greece that afternoon to spend three weeks with their family. Two other service users went with staff to take the service user to the airport. Once a fortnight they go to London for the weekend to visit a relative. Service users are encouraged to be as independent as possible. Records sampled showed that service users often help to prepare meals and bake cakes if they want to. Staff were observed supporting service users to do their own laundry, go shopping and clean their bedroom. Service users were observed to help bring the shopping in from the car. Service users decided between themselves who was going to wash and dry up after lunch. Service users said that staff help them to be independent and do all the housework so they can prepare to live on their own in the community. Menus are based on healthy eating plans and the Dietician had been involved in developing them. One service user said at a meeting that they would like to have more food that reflects their cultural background. Cookery books that reflect this had been bought. The Manager said that they plan to give the service user some of the food money each week so that they can buy their own food. This will also develop their independence skills. Staff said that they do not always stick to the menus as each person has different tastes and they accommodate these. Each person had what they wanted for lunch, which included sandwiches, pork pies, yogurt and cake. One of the service users was preparing cottage pie for the evening meal. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported or encouraged to undertake personal care in a way and at a time suited to them. Healthcare monitoring has improved but the monitoring of service users weight needs to be consistently recorded to ensure that individual needs are met. Adequate arrangements are in place to ensure the management of the medication protects service users. EVIDENCE: Service users were dressed appropriately to their age, the weather and the activities they were doing. They said that they have their haircut at local barbers and go out with staff to buy their own clothes. Service users had individual styles of dress and hair. Care plans sampled stated how staff are to support the individual with their personal care and hygiene. Service users records sampled showed that health professionals are involved in their care. These include the Psychiatrist, Community Nurse and Reflexologist. Records sampled showed that service users are supported to have regular health checks with the dentist, optician and chiropodist. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 15 Each service user had a health action plan. This is a personal plan about what a person can do to stay healthy and what healthcare services they need support to access. Records sampled stated that service users should have their weight checked regularly. The weight record stated what their target weight was. One record showed that the service user had not been to the weight clinic since May despite their record stating they should go monthly. The Manager said that the person had wanted their last appointment cancelled as they had ate a lot during their holiday and thought they would have put on weight. Staff are to support them to eat healthily now they are back from holiday. The other service users records sampled showed that their weight had not been checked since April. Their care plan stated that they sometimes do not eat and could be at risk of losing weight. Therefore, it is important that individuals weight is monitored to ensure they are eating well and having a healthy diet appropriate to their needs. Medication is stored in a locked cabinet and is supplied by Boots using the monitored dosage system. Medication Administration Records (MAR) had been signed appropriately. The MAR cross-referenced with the monitored dosage packs indicating that medication had been given as prescribed. Staff complete a weekly audit of the medication to check that it is being given appropriately. Where service users are prescribed PRN (as required) medication a protocol is in place stating when, why and in what dosage this should be given to the individual. Each service user has a list of the homely remedies that can be taken with their prescribed medication for pain relief and minor ailments. These were signed by their GP. All staff complete the accredited ‘Safe Handling of Medicines’ course before they give medication to service users. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure so that service users views are listened to and acted on. Producing this in a format that all service users can access will ensure all views are listened to. Arrangements are in place so that service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is included in the statement of purpose of the home and the service users guide and each service user has a copy of this. Staff said that the complaints procedure is going to be put in a format using pictures to make it easier to understand. They will then go through this with service users at the next meeting. The pre-inspection questionnaire states that there have been no complaints made about the home in the last 12 months. The CSCI had not received any complaints. The Manager said that they had received compliments from relatives about the service provided but these were not recorded. It is recommended that these be recorded so that these can be used as part of the homes quality assurance system. All staff had received training in adult protection and the prevention of abuse. Some service users can at times display behaviour that can be challenging. All staff had received training in using Positive Response (PRT) interventions to manage this behaviour and to prevent service users from self-harm. The Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 17 Manager said that refresher courses in PRT are booked for those members of staff who need it. Service users records included an inventory of their belongings that was completed when they started living at the home. They had not been updated since. They should be updated when service users buy new possessions and signed by them and a member of staff. Two service users financial records were sampled. Records showed that service users regularly receive their benefits paid into their bank accounts. The money held securely in their individual wallets cross-referenced with the amount stated on their record. Receipts are kept of all purchases. The previous manager was the appointee for service users. The Manager said that she would prefer not to be the appointee as service users would be able to manage their own money. All service users go to the bank to collect their money. Although staff go with them they do not need support to sign for or cash their money. Service users money is stored securely in the home but they are supported through training programmes to manage their own money. Therefore, the Manager will be asking the benefits agency if service users can increase their independence by not having an appointee. When service users buy large items this is discussed with their key worker and the Manager to ensure they have enough money and this is something they will benefit from. Service users are encouraged to save money for large items. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, safe and clean environment that meets their individual needs. EVIDENCE: The home is well decorated and furnished. Since the last inspection new furniture has been provided in the dining room. This was modern and was appropriate to meet the needs of the people who live in the home. New flooring has been fitted in the hall. There is a lounge and a separate quiet room with table football and darts provided for use by service users. There is another room that is used as a training room and also service users can use the computer there. Staff said that they do individual menus and activity plans with service users on the computer. There is a separate laundry and staff said that service users are supported to do their own washing. There is space for staff to support them and this was observed during the day. Since the last inspection a new dishwasher, crockery and fridge/freezer had been provided so ensuring that the risks of cross-infection are minimised. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 19 The first floor landing had recently been redecorated. Three service users bedrooms were seen. These were decorated and furnished according to individual tastes and interests. They contained many personal possessions. Each service user had their own en suite with a WC and shower. One service users said that they do not use their shower as they prefer to have a bath but the bathroom is near to their bedroom. In the garden there is a barbecue and an area where service users and staff can smoke. The garden is quite small but is well kept with grass and flowerbeds. The home was clean and free from offensive odours throughout. Service users are supported to clean their bedrooms and the communal areas of the home. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough staff to meet the needs of the service users accommodated. Service users are supported by staff they know and who have received training so they can meet their individual needs. Service users are generally protected by the home’s recruitment policy and practices. EVIDENCE: The pre-inspection questionnaire stated that 62 of care staff had NVQ level 2 in Care or above. This exceeds this standard of at least 50 of staff having completed this training. Rotas showed and the Manager said that four of the service users have 1:1 staffing and two of the service users need minimum staffing levels so there are usually four to five staff on each shift during the waking day. Four staff had recently been recruited to work at the home and two of those were on induction so were extra to the staff on each shift. New staff receive a three-day induction course. All but two staff that are currently working part-time while studying at university had completed the Learning Disability Award Framework (LDAF) course. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 21 Regular staff meetings are held and the majority of staff attended these. These are focussed on service users and how staff are supporting them to meet their needs and achieve their goals. Three staff recruitment records were sampled. These included proof of the person’s identity, a completed application form and evidence that they are physically/mentally fit to do the job they are employed to do. One of the records did not include two written references. This member of staff started earlier that week. Evidence that Criminal records Bureau (CRB) checks had been undertaken was available to ensure that staff employed are suitable to work with the service users. A staff training matrix was available. This showed that staff had received training in moving and handling, fire safety, risk assessment, health and safety, food hygiene and infection control. Since the last inspection all staff have received training in mental health, autism, adult protection and the prevention of abuse, Positive Response Training and Nutrition and Health. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users views underpin all self-monitoring, review and development by the home. Generally the health, safety and welfare of service users is promoted and protected. EVIDENCE: The previous manager left last year. Since the last inspection an Acting Manager has been in post. An application for them to be registered with the CSCI is being processed. At the time of writing this report the inspector had recommended that the Manager be registered. The Manager had completed NVQ 4 in care and management and had completed relevant courses to ensure that service users needs are met. Service users said that the Manager listens to them and supports them well. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 23 The organisation completes a yearly audit of the home. These consider the views of service users and their relatives where appropriate. At the last audit the home scored between 92 – 100 in supporting people to make decisions, being a good place to live, valuing individual personal care and support, preferred way of life and managing the home. In staff training and supervision they scored 59 . However, training records showed that this had improved since the audit took place. A representative of the organisation visits the home monthly as required under Regulation 26 and a report of these visits is forwarded to the CSCI. Records sampled showed that service users and where appropriate their relatives are involved in their reviews. Fire records showed that staff regularly test the fire equipment to make sure it is working. Regular fire drills are held so that staff and service users know what to do if there is a fire. An engineer serviced the fire alarm in June. Service users and staff had received training in fire safety in June so that they know how to prevent fires and what to do if there is a fire. A detailed fire risk assessment is in place to ensure that the likelihood of a fire starting is minimised as much as possible. Risk assessments are in place for staff, the premises and food safety. These are reviewed annually and updated if there are any changes. A Corgi registered engineer tested the gas equipment in April to make sure it is safe to use. They stated that it was in a satisfactory condition. An engineer completed the five-yearly electrical wiring test in 2002 and stated that it was in a satisfactory condition. The home has a vehicle that is used to transport service users. A valid certificate of insurance was seen for the vehicle. Records showed that in April the vehicle was serviced and passed its MOT. Staff said that a new vehicle is being purchased in September. Staff had not tested the water temperatures since 31 May 2006 to make sure they are not too hot or cold. At that test they were between 39 – 43 degrees centigrade. The recommended safe temperature is 43 degrees centigrade. These must be regularly tested to ensure that these temperatures are maintained. A valid certificate of employers liability insurance was displayed. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 2 3 X 3 X 3 X X 2 X Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA19 Regulation 12(1)(a) 13(2)(b) Requirement Timescale for action 12/08/06 2. YA22 22 3. YA34 4. YA42 7 9 19 Sch2 13(4)(a-c) Evidence that each service user has been weighed regularly according to their individual needs must be available. A complaints policy in an 31/08/06 accessible format for service users must be provided. Outstanding from the last inspection. Two written references 31/08/06 must be available in the home for all staff employed there. Water temperatures must 12/08/06 be tested monthly to ensure that they are maintained at 43 degrees centigrade. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 26 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. 3. Refer to Standard YA5 YA22 YA23 Good Practice Recommendations Service users individual contracts with the home should be available in the home. Compliments received about the home should be recorded. Inventories of service users belongings should be regularly updated. The service user and a member of staff should sign it. Sparrowfields DS0000032644.V293677.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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