Inspection on 05/12/08 for The Mount

This inspection was carried out on 5th December 2008.

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

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

Other inspections for this house

The Mount 10/11/09

The Mount 17/04/07

The Mount 05/07/06

The Mount 15/12/05

The Mount 04/10/05

The Mount 16/11/04

The Mount 22/06/04

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 27/02/2009.

CARE HOME ADULTS 18-65 The Mount Wood Lane Yoxall Staffordshire DE13 8PH Lead Inspector Dawn Dillion Unannounced Inspection 5th December 2008 09:30 DS0000028634.V373469.R02.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 DS0000028634.V373469.R02.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. DS0000028634.V373469.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address Wood Lane Yoxall Staffordshire DE13 8PH 01543 472081 F/P 01543 472086 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) Rebecca Homes Vacant Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places DS0000028634.V373469.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability (LD) 7 Mental Disorder (MD) 7 The maximum number of service users to be accommodated is 7. 2. Date of last inspection 17th April 2007 Brief Description of the Service: The Mount is a residential home located in the village of Yoxall, Staffordshire. The home provides a service for people who have a learning disability or a mental disorder. The large detached house is set in extensive grounds; stables on the site have been converted into a sensory and computer room. The home offers seven single bedrooms, three provide and en suite toilet. People have access to a lounge; separate dining and relaxation room and also an indoor swimming pool. Staffing is provided on a 24-hour basis, this ensures people are provided with support and assistance when required. People have access to relevant healthcare services if and when required. Individuals are encouraged to be independent to enable them to live independently in the future. The fees charged for the service provided at The Mount is £1,375.00p per week with an additional cost of £10.71p per hour for a one to one service. These fees applied on the day of our visit, the reader may wish to contact the service for up to date information. DS0000028634.V373469.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The unannounced key inspection of The Mount was undertaken within eight hours. The inspection methods used to establish the quality of care provided and the effectiveness of the management of the home, involved looking at care records. Talking to people who use the service and staff members. We, the Commission for Social Care Inspection looked around the home to ensure it was suitable and safe to meet people’s needs. Information from the service Annual Quality Assurance Assessment (AQAA) is also included in this report. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We received three surveys from people who use the service and five from staff members. This told us what people thought about the quality of the service provided. The registered provider (owner) was present on the day our visit. What the service does well: What has improved since the last inspection? DS0000028634.V373469.R02.S.doc Version 5.2 Page 6 The loft had recently been converted into a bedroom, which provided an en suite shower/toilet. We have registered this conversion confirming its suitability to meet people’s needs. 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. DS0000028634.V373469.R02.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 DS0000028634.V373469.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who wish to use the service are provided with relevant information to enable them to make a decision of the homes suitability to meet their assessed care needs. Appropriate assessment of people’s care needs ensure they will receive the support they need to promote their health and welfare. EVIDENCE: The home’s Statement of Purpose provided information about the service and facilities available to people. For example, the number of bedrooms and communal areas offered, staff’s qualification and experience, the management structure, social activities, how to make a complaint, the fees charged for the service, amongst other things. People also had access to a Service User Guide, which was published in a pictorial format to promote people’s understanding. This document provided additional information about the service available. DS0000028634.V373469.R02.S.doc Version 5.2 Page 9 These documents ensured people had relevant information, enabling them to make a decision of the services suitability to meet their assessed care needs promoting their health and welfare. A survey received from a person who used the service confirmed they had received a ‘Resident Pack,’ this told them all they needed to know about the home before they moved in. This also helped them to decide whether the service would be suitable to meet their assessed care and social needs. Discussions with staff and care records we looked at showed a needs assessment was undertaken before people moved into the home. This enables the home to establish if they can meet the person’s care needs before they move in. The service AQAA stated, “We have good holistic assessments for new residents.” One person who used the service informed us they had visited the home before making a decision to move in. This gave them the opportunity to look around the home and make a decision of whether the home would be suitable for them. DS0000028634.V373469.R02.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident their assessed care needs will be met to promote their health, safety and independence. People can make decisions on the support and assistance they need to ensure their health and welfare. EVIDENCE: We looked at two care records; both showed the support and assistance people required to promote their health and welfare. For example, one person displayed challenging behaviour; records showed they had access to a psychologist for support and to assist staff in managing these behaviours properly. DS0000028634.V373469.R02.S.doc Version 5.2 Page 11 One care record showed a person had access to relevant healthcare professionals to help them manage their anger. We also saw an ‘Incentive Chart,’ this encouraged positive behaviours; the chart was completed by the person, enabling them to monitor their progress and promote their rights and independence. Care plans provided staff with information on how to manage challenging behaviours. For example, using the ‘re-directive’ approach, this is where staff will try to remove or distract the person away from what may be upsetting them. This will ensure the person’s safety and the safety of other people. Discussions with the registered provider confirmed staff members had received training about the management of challenging behaviours and further training had been arranged. This was also identified in the home’s Statement of Purpose and confirmed by a staff member. This should ensure staff members are skilled and competent to manage challenging behaviours properly. Care records showed people were involved in planning their care; records were reviewed regularly to reflect people’s changing care needs. Information received from staff and the service AQAA showed weekly individual support meetings were undertaken to review people’s care needs. This ensured people received the appropriate support and assistance to meet their physical and mental health needs. Information from a survey confirmed people were involved in planning their weekly routine. It stated, “We do a weekly planner for activities, college and appointments.” There was a risk assessment in place to provide staff with guidance on how to manage challenging behaviours and other potential risks, promoting people’s independence whilst ensuring their safety. Signatures on risk assessments showed people were involved in developing and reviewing their assessment. This promoted the individual’s choice, rights and independence. A risk assessment identified one person needed the assistance of a male staff when they displayed challenging behaviours. Staff confirmed the person responded well to male staff members. Staff told us a male member was usually on duty. In the absence of a male staff, staff confirmed they had access to other staff within the company if and when necessary. We looked at staff working rotas, which showed a male member of staff was frequently on duty. We also observed two male staff members present on the day of our visit. DS0000028634.V373469.R02.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 good. This judgement has been made using available evidence including a visit to this service. People are able to pursue their chosen social activity and maintain contact with their local community, promoting people’s rights and independence. People are offered meals that reflect their choice and dietary needs to ensure their health. EVIDENCE: Staff confirmed people have the opportunity to learn new skills to promote their independence. Care records included an ‘Independent Living Plan.’ This enhanced people’s skills to enable them to live independently. The plan DS0000028634.V373469.R02.S.doc Version 5.2 Page 13 provided information about the support people needed with shopping, cooking, budgeting, healthy living, health and safety, education and occupation. The home also had a brochure about encouraging independence and supporting people whilst in their local community. For example it told us about links with the community to enable people to pursue outdoor activities. The service AQAA stated, “We have variety and choice and feel this has improved.” “People have the opportunity to develop and use independent living skills, through self directed, budgeting, cooking, shopping and community based activities.” Discussions with staff and care records we looked at showed people who used the service did not have any specific religious needs. However, one care record showed a person wanted to attend Midnight Mass. Discussions with the person and staff confirmed they would be attending Midnight Mass. There was no one in residence from an ethnic background, the registered provider confirmed they would be able to provide a service for people from different ethnic groups and would access relevant services to assist with communication and culture awareness. People were able to access the local college to learn new skills, one person said they were undertaking a course at Burton College and had recently achieved an ‘Award in Food Safety in Catering, Level 2’. A care record showed another person was undertaking a computer course. The service AQAA stated, “Staff assist and accompany service users to attend college, with the opportunity to attend voluntary and paid employment.” People confirmed they had access to leisure services within their local community. Three people told us about their planned daily activity which consisted of Christmas and food shopping and attending college. We looked at one ‘Weekly Planner,’ this showed the individual’s planned weekly activity, which included attending the gym, managing their finances, food shopping, gardening, dining out and domestic tasks. Staff told us these plans were flexible to reflect the person’s choice throughout the week. The Service User Guide showed additional social activities available such as, horse riding, bowling, swimming and sailing. This provided people with a variety of activities to reflect their interests. Care records showed people were able to maintain contact with their family and friends. One person said they enjoyed visiting their relatives. Another person said they would be spending Christmas with their parents. The Service DS0000028634.V373469.R02.S.doc Version 5.2 Page 14 User Guide also confirmed people were able to have visitors. This ensured individuals were able to maintain contact with people important to them. Discussions with staff and care records showed people had access to professional services relating to intimate relationships. This promoted individuality and the person’s rights. For example, access to a family planning clinic for sexual education. We observed the daily routine to be relaxed, we saw people preparing their evening meal, others listening to music and watching the television. This showed people’s choice of pastimes was respected, to promote their individuality and independence. We saw bedroom doors were fitted with a security lock, this ensured people’s privacy. Discussions with one person confirmed they had a key to their bedroom and the front door of the home. This encouraged people to be independent. The home had a three-week menu; staff confirmed people were involved in planning the menu. We looked at the home’s menus, which showed people were offered a variety of meals. The menus did not show an alternative choice of meals. However, staff confirmed people were able to choose what they wanted. Staff confirmed no one required a specific diet relating to their culture or religion. Further discussions with staff confirmed they would make every effort to meet any dietary needs. Care records showed one person had access to a Dietician, assisting them to plan their menu, promoting healthy eating. We observed one person had gone food shopping; we later saw them preparing a chicken casserole with the assistance from staff. The person said they always prepared and cooked their own meals. DS0000028634.V373469.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to ensure their assessed care needs are met, promoting their health and welfare. Medication practices were not entirely thorough to ensure people receive their medicines properly to promote their health. EVIDENCE: Discussions with staff and care records showed people were offered an annual health check. This information was also contained within service AQAA. This should ensure people’s physical and mental health is monitored and maintained. DS0000028634.V373469.R02.S.doc Version 5.2 Page 16 The home’s Statement of Purpose stated, “Certain service users may require additional support, in which event the care requirement will be assessed to cater for the individual.” Care records showed people had access to relevant healthcare services to promote their health, such as a Community Nurse, General Practitioner, Dentist and Family Planning. The Service User Guide also showed people had access to a Speech Therapist and Psychologist. Staff told us people had access to a ‘Health Facilitator,’ this person provided support and advice on all healthcare matters. They also provided advice on menu planning, to encourage healthy eating amongst other things. We looked at the service’s medication practices and systems; staff confirmed they had received half day training, showing them how to use the medication system safely. Some staff members had received a 12-week course about ‘Safe Handling of Medicines.’ This should ensure staff have the skills to manage people’s medicines safely. We looked at medication administration records, which showed staff had signed these when medicines were given out. This provided a record to show people were receiving their prescribed medicines to ensure their health. Discussions with staff confirmed one person self-administered their medicines; there were no risk assessment or any monitoring system in place to ensure this person was taking their prescribed medicine. Staff also confirmed this person had not asked for this medicine since being admitted to the home on 25 January 2008. Further discussions with staff confirmed they were not sure if this person was actually taking their medication. The registered person must ensure people receive their prescribed medicines to maintain their health. The registered provider confirmed a risk assessment would be put in place to ensure this person takes their prescribed medicines safely. We looked at this person’s care records; there was no recorded evidence of concerns about the person’s current health. DS0000028634.V373469.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to the home’s complaint procedure, enabling them to share their concerns and promote their rights. Policies and procedures adopted by the home protect people from the risk of abuse. EVIDENCE: People had access to the home’s complaint procedure which was published in plain English and pictorial format to promote people’s understanding. The document showed photographs of staff members’ people could share their concerns with. A survey received from a person who used the service confirmed they would talk to the manager, staff or their social worker if they were unhappy. Another survey also confirmed they would know who to talk to if they had any concerns. Records showed complaints received by the home were recorded and also showed actions taken to resolve the concern. This should ensure people’s rights. DS0000028634.V373469.R02.S.doc Version 5.2 Page 18 We received one complaint about the service since the last inspection visit. A person who used the service contacted us by telephone, informing us about a sensitive matter. This was resolved by the home and the person’s social worker. Further contact with the complainant confirmed they were satisfied with the outcome. The service AQAA showed the home had received three complaints; these were relating to domestic issues and were resolved by the home. Two safeguarding referrals were made to Social Services. This is where there has been an allegation of potential abuse. These allegations were of a sensitive nature and were investigated by Social Services. There was no evidence of poor practices. Staff training records and the service’s Statement of Purpose showed staff members had received safeguarding training. This should ensure staff are aware of the various aspects of abuse and are able to recognise the signs to ensure people’s protection. We spoke to one staff member who confirmed she had received safeguarding training; they also informed us that signs or allegations of abuse would be reported to Social Services and to us. Care records and discussions with staff confirm physical intervention is sometimes used to maintain the safety of people. This is where staff may need to physically restrain a person from harming themselves or others. Staff training records, the home’s Statement of Purpose and discussions with staff confirmed they had received physical intervention training, to ensure the safety of people whilst undertaking this technique. Staff informed us that some people were responsible for their financial affairs and in some cases Social Services were appointees. This is where the Local Authority looks after people’s money because they are not able to do so themselves. The home did not maintain any finances for people who used the service. DS0000028634.V373469.R02.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. The design and facilities provided within the home are suitable to meet people’s needs, to ensure their safety, independence and comfort. EVIDENCE: The Mount is located in a rural area of Yoxall, Staffordshire. The Large detached property is set within its own grounds with neighbouring stables that had been converted to provide a sensory and computer room. The home now offers seven single bedrooms located on the ground and first floor. The loft had recently been converted into a bedroom, which also provided an en suite shower room. Three out of seven bedrooms were provided with en suite toilets. DS0000028634.V373469.R02.S.doc Version 5.2 Page 20 The home also provided a bath/shower room and separate toilets, which were located near to bedrooms and communal areas. Equipments and adaptations were not provided and these were currently not required for people who used the service. People had access to a lounge, dining room, snooker room, kitchen and separate laundry, relaxation room and an indoor swimming pool. The property was suitable to meet people’s needs to promote their independence and safety. We saw risk assessments in place for the swimming pool and for fire safety. People were encouraged to participate in domestic tasks, to maintain the cleanliness of the home. This promoted people’s independence and ensured they lived in a clean and welcoming environment. DS0000028634.V373469.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Skilled and competent staff ensure people’s assessed care needs are met to ensure their safety and welfare. Staff recruitment practices ensure people are protected from potential abuse. EVIDENCE: We looked at staff training records, which showed 50 of the staff group had achieved the National Vocational Qualification. One staff member told us they had obtained the National Vocation Qualification, Level 3 ‘Promoting Independence.’ This should ensure staff are skilled and competent to meet people’s care needs. Staff personnel records showed the homes recruitment procedure was thorough to ensure people were protected from potential abuse. For example we saw Criminal Record Bureau (CRB) and a Protection of Vulnerable Adults DS0000028634.V373469.R02.S.doc Version 5.2 Page 22 (POVA 1st) checks and written references were obtained prior to staff commencing employment. One staff member confirmed they had these safety checks. These checks should provide some assurance that staff members are suitable to work in the home. The service AQAA also showed people who used the service were involved in staff recruitment. This should ensure people have a choice of what staff member work with them to assist with their care needs. The service AQAA told us they strived to have a good training package. Training records showed staff had received the following training: Moving and Handling, Mental Capacity Act, Risk Assessment, Fire Safety, Managing Challenging Behaviours, Protection of Vulnerable Adults amongst offers. This should ensure staff members are skilled to meet people’s care needs properly. One staff member confirmed they had received the training and also informed us they were currently undertaking physical intervention training. This enables staff to assist people who display challenging behaviours and ensure the person’s safety. DS0000028634.V373469.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration is based on promoting people’s independence and rights enabling them to live a lifestyle of their choice. Quality assurance systems ensure people’s views are respected to promote their rights. EVIDENCE: DS0000028634.V373469.R02.S.doc Version 5.2 Page 24 The registered manager for the service resigned in September 2008, the registered provider (owner) told us a manager had been appointed but would not commence work until February 2009. The registered provider was managing the service to ensure standards were maintained. Discussions with the registered provider confirmed she had ten years experience in social care and had obtained the National Vocational Qualification Level 4 in Management and the Registered Managers Award. One staff member told us the management support was excellent and stated, “She is wonderful and always finds the time to talk to you.” The service AQAA did not provide full information to reflect the service provided to meet people’s care needs. The registered provider confirmed this would be completed in more detail in future to show the service provided in the home. The Service AQAA identified the home had extensive audit tools based on the views of people who use the service and the staff group. This should ensure people’s rights and independence are promoted. The home’s Statement of Purpose showed regular meetings were held with people who used the service. This enables people to discuss areas that can improve the service. The service AQAA stated, “We have monthly resident meetings to say how the home is run and what could be improved.” Staff informed us that a manager from another home within the company, undertakes monthly inspection of the service. This ensures that quality standards are maintained and people’s care needs are met. We saw safety records maintained; a fire risk assessment was in place. Weekly health and safety checks were undertaken on the property to ensure people’s safety. DS0000028634.V373469.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 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 X 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 DS0000028634.V373469.R02.S.doc Version 5.2 Page 26 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 A written risk assessment must be put in place for people who self-administer their medicines. This will ensure people are taking their medicines regularly and safely, to ensure their health and welfare. Timescale for action 28/02/09 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 YA39 Good Practice Recommendations To ensure the service AQAA is completed in more detail and should be used as a tool to assess the development and quality of the service. DS0000028634.V373469.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000028634.V373469.R02.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. 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