Inspection on 26/02/07 for Wheatley Lane

This inspection was carried out on 26th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wheatley Lane 04/10/07

Wheatley Lane 23/03/05

Wheatley Lane 19/07/04

Wheatley Lane 21/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Wheatley Lane 21-25 Wheatley Lane Lee Mount Halifax West Yorkshire HX3 5HN Lead Inspector Cheryl Stovin Key Unannounced Inspection 26th February 2007 02:39 Wheatley Lane DS0000001020.V329124.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 Wheatley Lane DS0000001020.V329124.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 Older People and 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. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheatley Lane Address 21-25 Wheatley Lane Lee Mount Halifax West Yorkshire HX3 5HN 01422 320986 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) Bridgewood Trust Limited Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23rd February 2006 Brief Description of the Service: 21,23 and 25 Wheatley Lane are properties that are managed by the Bridgewood Trust, which is an organisation that provides accommodation and care for adults with a learning disability in the Calderdale and Kirklees areas. The three houses on Wheatley Lane are situated in a residential area with easy access to the town centre of Halifax. The houses, which are adjoining, each provide accommodation for two people. The houses are well maintained and are furnished and fitted to a good standard. The weekly charges in the home are subject to individual assessment depending upon the level of care to be provided. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered during a Key Inspection. This included an unannounced visit to Wheatley Lane on 26th February 2007 by one inspector over a period of 4 hours. During this visit discussions were held with service users and the acting manager, records were examined and some areas of the home were seen. In addition to this visit comment cards were sent out to the service users and their relatives to give people an opportunity to share their views of the service with CSCI. No service users had completed and returned their comment cards at the time of writing the report. Three relatives responded, and all were very positive about the care provided within the home. The last inspection took place on 23rd February 2006, no additional visits have been made. A pre-inspection questionnaire was not sent to the home, however, the information was made available during the visit.. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: The visit took place during the afternoon and early evening and the atmosphere was relaxed and homely. The service users were assisting the staff in preparing the evening meal and were working together as a team. The service users live active and varied lives and participate in a wide range of community social and recreational activities. The service users were looking forward to going swimming on the evening of the visit. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 6 Service users are encouraged to contribute to the decision making process and their views influence the way the home is run. The home is well maintained and furnished and fitted to a good standard. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are fully assessed. Service users have written information about the terms and conditions in the home. EVIDENCE: The home has produced a Statement of Purpose and Service User guide, which details the services and facilities provided in the home. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 9 There have been no new admissions to the home for several years, therefore, it was not possible to assess the admissions procedure. Service users needs are assessed and recorded in their plan of care. Each service user has a licence agreement held on file which details the rights and responsibilities of each party. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed and the home has a good approach to promoting the service users health care. EVIDENCE: Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 11 All of the service users care records were seen. All contained a personal support plan detailing their daily support needs. A daily record is kept of the support given. The plans are regularly reviewed with service users confirming that they fully participate in the process. The home is in the process of reviewing the care plans and implementing a person centred planning approach. This will greatly improve the standard of the care plans and fully involve the service user in planning their care and identifying their goals and aspirations. Service users health care needs are assessed and an ‘OK health check’ completed. This is a recognised tool for assessing and planning the health care needs of adults with a learning disability, and a health action plan devised where appropriate. All of the service users said that they always make decisions about what they do each day. Service users are encouraged to take responsible risks with detailed risk assessments in place. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 13 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live active and varied lives, and are encouraged to make use of a wide range of community social and recreational activities. EVIDENCE: Service users live active and varied lives, and are encouraged to make use of a wide range of community social and recreational activities. Service users are encouraged and enabled to develop and maintain independent living skills and to undertake meaningful activities. During the week the service users engage in a range of structured activities, some residents attend college and others attend workshops run by the Bridgewood Trust organisation. Service users are encouraged to participate in valued and fulfilling activities. One service user works voluntarily in a charity shop, whilst another enjoys voluntary work at an Age Concern day centre.. Service users are encouraged to make use of a wide range of appropriate leisure and social activities, either individually or collectively. Service users live active and varied lives and some activity usually takes place each evening and at weekends. All service users have access to televisions and DVD’s and videos. Holidays are arranged the duration and destination dependant upon individuals preferences, last years destinations included Scarborough and Wales. Service users receive varied and healthy meals, the main meal of the day being taken in the evening. The service users are encouraged to assist with the cooking and preparation of meals. The home generally adheres to a four week menu, however, this can be changed to suit the preferences of the individuals. The evening meal being served on the day of the inspection was pizza and salad. This was a light meal due to the service users going swimming later in the evening. Service users are actively encouraged to maintain contact with their families and friends and encouraged to mark birthdays and other special occasions. All of the respondents to the relatives comment cards said that they felt the care home meets the needs of their relative. There were the following additional comments: Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 14 “My sons needs are always taken into consideration with everything they do and plan to do”. “I am very impressed with the support given to my relative and the other people who live at Wheatley Lane”. “My relative is not easy to enable choice because of his level of dependence and behavioural problems. I am very impressed with the dignity and genuine care that the staff give”. “I am really pleased with the quality of life that my relative has at Wheatley Lane. They work hard at the interface with his daily activities and this is not always easy”. “I feel this care home is excellent in every aspect of care and cannot fault them in anyway”. One relative listed the aspects in which the care home does well as follows: Integration: “e.g. Activities like eating out for birthdays”. Involvement: “e.g. Social activities that includes us”. Family contact: “e.g. assisting with birthday and Christmas cards and presents”. Choice: “e.g. choosing activities, food and clothes”. Individual care: “e.g. respecting his likes/dislikes, balance of doing things together or one to one”. Enabling: “e.g. supporting with household tasks and transport, using public transport which he really enjoys. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 15 Care: “e.g. genuine concern for him and noticing and praising him”. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users personal and health care support needs are met and support is given in accordance with their wishes. Service users are protected by the medication policies and practices within the home. EVIDENCE: Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 17 Service users personal and physical and emotional health care support needs are assessed and form part of their plan of care. All personal care is given in private and in accordance with the service users preferences. Service users physical and psychological health care needs are assessed and detailed in their personal care plan. The home uses a monitored dose system for the administration of medication. The medication is securely and appropriately stored. Each service user has an individual medication profile which details the medication prescribed and what medical condition it is used to treat. Medication administration records were seen to be accurately completed, and stocks of medication reconciled with records kept. All service users have recently had a review of their medication. This has resulted in a reduction of medication prescribed with no apparent adverse effects. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are acted upon. Service users are protected from abuse and neglect. EVIDENCE: The home holds a complaints procedure. Each of the service users are given a pictorial and written copy of the procedure to follow. All of the completed comment cards indicated that they knew who to talk to if they were unhappy about anything in the home. One relative made the additional comment: “I would speak to the manager in the first instance but I have the number for Bridgewood office and would alert the CSCI if I had concerns”. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 19 All staff have received training in the protection of vulnerable adults and the staff on duty at the time of the visit were aware of the procedure to follow if they suspected abuse was taking place. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24.25.26.30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, with high standards of cleanliness throughout, providing a pleasant, and safe environment for service users. EVIDENCE: Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 21 The home is well maintained both internally and externally and is furnished and fitted to a good standard, with a routine programme of maintenance and refurbishment. The accommodation is situated in a residential area close to the facilities of the town centre of Halifax. The establishment is indistinguishable from neighbouring properties. All of the bedrooms are furnished and fitted to a good standard with the service users choosing the décor. The bedrooms are spacious and service users are encouraged to personalise their rooms to reflect their tastes and hobbies. The service users are obviously very proud of their own rooms which they are encouraged to keep clean and tidy. Communal areas are spacious and comfortable and well furnished and decorated. The home was seen to be clean and hygienic throughout and service users confirmed that this was always the case. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users do not benefit from a consistent and stable staff team. Service users are protected by the home’s recruitment practices. EVIDENCE: There have been high levels of staff turnover in the last year. The home is currently staffed by bank staff. It is acknowledged that the bank staff have Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 23 worked at the home for a number of years and are well known by the service users. This is no substitute, however, for a permanent and stable group of staff. Records seen showed that there are sufficient staff on duty to meet the needs of the service users, including social and recreational activities. The bank staff have received only mandatory health and safety and protection training. No member of staff holds or is undertaking National Vocational Qualifications (NVQ) in care. Recruitment is underway to appoint staff to permanent posts. One relative commented in the returned survey: “There have been a lot of bank staff recently due to staffing turnover, but I have never had concerns that they are not able to do the job, it’s just unsettling for the residents. I have discussed this with the manager and I know they are doing all they can”. Recruitment practices within the organisation are safe. All new staff are subject to the required pre-employment checks. A satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosure are obtained prior to an offer of employment being made. All of the staff records held at the home were seen and contained an application form, two written references and the CRB and POVA confirmations. The service users are involved in the selection procedure and their views fully taken into account. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed in the best interests of the service users. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 25 EVIDENCE: The current acting manager of the home is leaving the organisation shortly. An experienced manager from another home within the Bridgewood Trust will be taking over as manager of Wheatley Lane. They will be working together for a time to ensure a smooth transition. The new manager is currently nearing completion of the NVQ IV Registered Managers Award and will submit an application to be registered in respect of the home. There is a commitment to health and safety and safe working practices in the home. All staff receive mandatory health and safety training with regular updates. Fire drills are carried out on a regular basis and all staff receive fire safety training. Detailed risk assessments are in place which are reviewed and updated on a regular basis. Certificates were seen which showed compliance with gas and electrical regulations. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 26 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 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 3 26 3 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 2 32 1 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT Standard No Score 37 3 38 3 39 3 40 x 41 x 42 3 43 x 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 Wheatley Lane Score 3 3 3 x DS0000001020.V329124.R01.S.doc Version 5.2 Page 27 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 YA32 Regulation 18 Requirement A programme of NVQ training must be in place to ensure that 50 of the care staff are qualified to NVQ level 2 or equivalent. The manager must submit an application to the CSCI to be registered as manager of the home. Timescale for action 30/06/07 2 YA37 9 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA31 Good Practice Recommendations A team of permanent care staff should be in place to support the service users. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Wheatley Lane DS0000001020.V329124.R01.S.doc Version 5.2 Page 29 - 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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