Inspection on 15/11/06 for Wheelwright Road, 76-78

This inspection was carried out on 15th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wheelwright Road, 76-78 27/11/08

Wheelwright Road, 76-78 03/07/07

Wheelwright Road, 76-78 09/02/06

Wheelwright Road, 76-78 31/08/05

Wheelwright Road, 76-78 07/02/05

Wheelwright Road, 76-78 02/03/04

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Polesworth Group 70 Long Street

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10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Wheelwright Road, 76-78 Erdington Birmingham West Midlands B24 8PD Lead Inspector Sarah Bennett Unannounced Inspection 15th November 2006 01:15 Wheelwright Road, 76-78 DS0000016717.V311796.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 Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wheelwright Road, 76-78 Address Erdington Birmingham West Midlands B24 8PD 0121 686 6601 0121 686 8898 t.d.lyttle@blueyonder.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Ann Marie Lyttle Mr Thomas Lyttle Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years Mrs Lyttle must ensure that Mr Adrian Lyttle takes no part in the day to day operation and management of the home 9th February 2006 Date of last inspection Brief Description of the Service: 76 - 78 Wheelwright Road is an adapted domestic property situated in a residential area of Erdington. The two homes were previously registered separately but are now registered as one home, operated by the same owner. The home accommodates ten residents who have a learning disability in single and shared bedrooms on the ground, first and second floors. Bathrooms and toilets are available on all first and second floors and a separate toilet is provided on the ground floor in 78. Communal areas include a lounge and kitchen/dining room in each property. A separate office and a smoking room/conservatory are provided on the ground floor in 78. To the rear of the home is a pleasant garden and patio area. The home has a vehicle for transporting residents. The owner said that the fees charged vary from person to person but are based on the amount of staff hours needed to meet the individual needs as assessed by the social worker. They are on average about £700 per week. The CSCI inspection report is available in the home for visitors if they wish to read it. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 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. One inspector carried out the unannounced fieldwork visit over five and a half hours. This was the homes key inspection for the inspection year 2006 to 2007. The owner, the manager and the staff on duty were spoken to. The inspector met with nine of the residents 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: Residents said that they enjoy going out often to the places they want to go to. They said they like going to Butlins on holiday and choose to go there twice a year as they enjoy the entertainment. Each resident has a care plan so that staff know how to support the person to meet their needs and achieve their goals. Residents said they like helping out with things like cooking, cleaning, feeding the cat and doing their washing. One resident said, “ I am very happy with the staff and with my key worker.” Residents chatted to all staff and seemed to enjoy being with them. There are no staff vacancies so staff that work at the home know the residents well. Residents said they choose what they want to eat and were aware of what they should eat to stay healthy. Residents were well dressed and this was appropriate to their age, the weather and what activities they were doing. Residents are supported to keep in touch with their family and friends. There are often parties at the home to celebrate birthdays or special events such as fireworks. Residents can invite their friends and family to these. Residents are supported to keep healthy and have regular health check ups. Staff notice when residents are unwell and make sure that they go to the doctor. Residents are encouraged to do regular exercise such as swimming and going to the Special Olympics training. Staff have training in how to meet the needs of the residents so they can support them well. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 6 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. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether or not they want to live at the home. Arrangements are in place so that prospective residents individual needs and goals are assessed to ensure the home can meet them. EVIDENCE: The statement of purpose of the home and the service users guide to the home included all the relevant and required information. This provides prospective residents with the relevant information about the home and informs the residents what they are to expect from the home and staff. There were no vacancies for residents however, one resident was to move to another home due to their changing needs the following day. The owner said that they hope to fill this vacancy in the future. An assessment process is in place that assesses whether the home can meet the needs of any prospective residents before they move in. The owner said that initially the social worker would visit with the individual and then visits would follow to ensure the person gets to know the staff and the other residents. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 9 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 in individuals care plans so they know how to meet individuals needs and help them achieve their goals. Residents are supported to make decisions and are consulted on what goes on in the home. Arrangements are in place to ensure that residents are supported to take risks within a risk assessment framework so helping them to keep safe. EVIDENCE: Two residents records were sampled. These included individual care plans that stated how staff are to support individuals to meet their needs and achieve their goals. They included how individual’s needs are to be met with regard to their personal care, medication, diet, social activities, relationships, travel and independence skills. Care plans had recently been reviewed and updated if necessary to reflect any changing needs. A review is held annually for each resident at the home. The resident, their relatives or friends, their key worker and the owner or manager are invited as well as any professionals involved in the individual’s care. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 10 Residents contribute £10 per month for use of the home’s minibus. At the last inspection a requirement was made for an agreement to be in place stating that the individual or their representative had agreed to pay this. These are now in place and had been signed by the resident or their representative where the resident is not able to sign. There are eight members of staff who can drive the minibus so giving residents ample opportunities to benefit from this. Residents were observed making choices about what they wanted to eat, drink and where they wanted to spend their time. Regular residents meetings are held. These are chaired and minuted by a neighbour who acts as an independent advocate. Residents talk about what they want to do, where they would like to go for holidays and days out and anything they wish to discuss about the home. Resident’s records sampled included individual risk assessments. These stated what action staff are to take to minimise the risks to individuals. They included minimising the risks of tripping, burns and scalds, fire, using their bedroom, the kitchen and laundry, moving and handling, bathing and showering, using the minibus, stairs and hazardous substances. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 11 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. Arrangements are in place so that people living in the home experience a meaningful lifestyle. Residents are offered a healthy diet and enjoy their meals. EVIDENCE: Most residents attend day centres or colleges from Monday to Friday but some only attend a couple of days a week. On the days they do not go staff support them to go to a local hydrotherapy pool or to a sensory room or garden. Resident’s records sampled showed that they go out to local clubs for people who have a disability, take part in Special Olympics training, go shopping, to pubs, restaurants, go swimming, for walks and to parks. Records showed and the owner said that if residents do not enjoy going to some clubs they either stay at home relaxing or go out shopping or a drink with staff. There were photographs around the home of residents on holiday, at parties and doing Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 12 activities inside and outside the home. One resident said that they were planning to go to the cinema to see the new James Bond film. Residents had been on holiday twice during the year to Butlins at Bognor Regis where they said they love going and enjoy the entertainment there. Four residents were getting ready to go to Jersey the next morning for a long weekend with the Special Olympics club. They were looking forward to this especially as some of them had not been on an aeroplane before. Residents talked about the recent firework party that they had at the home that they said they enjoyed. It had also been one of the residents birthday and they had chosen to have a party at the home. Residents are supported to keep in contact with their families where appropriate. Relatives are invited to individual’s reviews. Some residents go to visit their relatives and maybe stay overnight or their relatives visit the home. Residents telephone their relatives and a pay phone is provided so that residents can speak to their relatives in private if they want to. Records showed and residents said that they make their own packed lunches for the centre, they set the table, wash up and clean their bedrooms. Residents were observed helping to prepare their evening meal, make their packed lunch for the next day and washing up. There is a kitchen/dining room in each side of the home and residents eat in the side where their bedroom is. Staff were observed sitting and eating with the residents and talking to them about their day and what they had been doing making the mealtime a social occasion. Food records sampled showed that a variety of food is offered that includes fresh fruit and vegetables. Residents who did not like the evening meal that was offered or because of their dietary needs were offered an alternative. Staff had good knowledge of which resident liked what food and any foods that they should avoid. A variety of fresh fruit was available. One resident said, “ My favourite foods that we have are Beef Stew, Lasagne and Spaghetti Bolognese, sometimes we have steak.” Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 13 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. Arrangements are in place to ensure that individuals personal care and health needs are generally well met. The arrangements for the management of the medication are generally sufficient to protect residents. EVIDENCE: Care plans sampled included details of how to support individuals with their personal care. Resident’s records sampled included individual moving and handling assessments. These stated how staff are to support the individual with their mobility if needed with minimal risk to the individual and staff. Residents were well dressed according to their age, gender and the activities they were doing. Residents said that staff support them to go out shopping for their clothes. One resident had their hair coloured and said that a member of staff had helped them to choose the colour and put it on. Residents said that they were staying in that evening and staff were going to paint their nails for them and they might also have a foot spa. One resident said they were going to go to bed early, as they had to be up early the next morning to go to Jersey. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 14 Records showed that residents are weighed monthly. One record showed that the person had gained 8lbs in the last two months. Staff said that their appetite had got better recently and they had also been prescribed medication that may mean they gain weight. Their weight should be monitored closely to ensure it does not continue to rise and they become overweight, which could lead to health problems. Resident’s records sampled included an individual Health Action Plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to use. The plans are produced using pictures so making them easier to understand. Health professionals are involved in the care of individuals where appropriate. These included the GP, Psychologist, Older Adults Nurse and Psychiatrist. One professional had stated in a report that one of the resident’s continence had improved through staff monitoring the individual’s dietary needs. Other records showed that staff had followed the advice of health professionals so ensuring that individual’s health needs were met. Records showed that residents had regular dental check ups, eye tests and went to the chiropodist where appropriate. One of the residents had been to the chiropodist earlier that day. The medication was looked at in number 76. Medication is stored in a locked cabinet. A local pharmacist supplies the medication for individuals each week in ‘Nomad’ packs. One of the residents Medication Administration Records (MAR) sampled staff had signed appropriately and it cross-referenced with the Nomad pack indicating that medication had been given as prescribed. The other residents MAR sampled had not been signed for that morning however, their medication was not in the Nomad pack so it would seem that it had been given. The owner telephoned the member of staff responsible as per the medication procedure. They returned to the home to sign the MAR appropriately as they had forgotten to sign it. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 15 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 arrangements for making complaints ensure that resident’s views are listened to and acted on. Arrangements are in place to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: Each resident had a copy of the complaints procedure in their file. This is not produced in an accessible format to the people who live in the home. However, the Manager said that rather than just getting a computer software package that will produce pictures or symbols he would prefer to do something that the individuals can really understand easier. He has spoken to day centres and to individual residents to ask how they would know from looking at a picture what it meant and what pictures or symbols mean to them. In doing this residents awareness of how to make a complaint would be raised and they are to be involved in developing the procedure. The complaints procedure included all the relevant and required information. The home or the CSCI had not received any complaints about this service in the last twelve months. Two residents financial records were sampled. The money in their individual purse/wallets cross-referenced with their individual records. Records showed that the individuals regularly receive their personal allowance and this is spent on personal items. Receipts are kept of all expenditure and these crossreferenced with individual records. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 16 Residents records sampled included an inventory of their belongings. These had been updated as residents had bought new things or items had been thrown away so it is clear if any items of individuals should go missing. Where residents had displayed behaviour that could be ‘difficult’ staff had looked at the reasons with health professionals as to why the individual was behaving in that way. Where appropriate behaviour management strategies had been developed for the individual and any identified triggers for the behaviour removed as much as possible. For one resident this had resulted in incidents of ‘difficult’ behaviour decreasing in the past two months. Staff had received training in adult protection and the prevention of abuse. Staff records sampled included evidence that a satisfactory Criminal Records Bureau (CRB) check had been undertaken before the individual started working at the home. This is to ensure that suitable people are employed to work with the residents. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 17 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. Arrangements are good to ensure that residents live in a homely, comfortable, safe and clean environment. EVIDENCE: The home is well decorated and maintained. In each side of the home there is a lounge and kitchen/dining room downstairs. All but one of the bedrooms in 76 are on the first and second floors. In 76 there is a laundry that is used by all residents. In 78 there is also a conservatory, office and WC on the ground floor. Residents have access to all parts of the home except other resident’s bedrooms. There is a garden at the rear of the home that can be accessed by all residents. Residents said they recently had the firework party in the garden and during the summer they had barbecues. At the last inspection a requirement was made for the chair frames in the lounge in 78 to be re-varnished as these were worn. This requirement had been met making the lounge look more comfortable. Resident’s bedrooms are personalised according to individual’s tastes and interests. Some residents share a bedroom but attention had been given to Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 18 ensure that residents had their individual space and residents were aware of this. Bedrooms contained many personal items including displays of medals and trophies that individuals had won at Special Olympics. In the first floor WC in 78 some of the paint on the toilet seat was chipped and paint had been splashed on it when redecorating. This needs to be replaced to ensure the risk of cross-infection is minimised and it is comfortable for residents to use. The home was clean and free from offensive odours throughout. Hand wash, hand towels and toilet rolls were provided in all the toilets so helping to minimise the risk of cross-infection. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 19 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, 36 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective staff team supports residents. Residents are protected by the home’s recruitment practices. Staff receive the appropriate training and support to meet the needs of individual residents and protect them from harm. EVIDENCE: One resident said, “I’m very happy with the staff and with my key worker.” Over 50 of staff have NVQ level 2 or above in Health and Social Care. Some staff that already have level 2 are now doing level 3. This meets the standard that at least 50 of staff have this qualification. The owner said that since the last inspection two members of staff had left however, these vacancies had been filled so there were no staff vacancies. Rotas showed that minimum staffing levels are met and bank or agency staff are not used to work at the home. This gives consistency to residents, as the staff that work with them know them well. Regular staff meetings are held either monthly or two monthly. Minutes of these are kept. All staff are expected to attend these and the individual needs of residents are discussed. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 20 Three staff records were sampled. These included the required recruitment records. They included evidence that a satisfactory Criminal Records Bureau (CRB) check had been undertaken for staff before they started working at the home to ensure that suitable people are employed to work with the residents. Staff records showed that when staff begin working at the home they have an induction to ensure they know what is expected of them, their job role and how to work with individual residents. Training records showed that staff receive training in food hygiene, infection control, first aid, fire safety, moving and handling, adult protection, health and safety, medication, autism, dementia, person centred planning and Makaton (sign language). Staff records showed that staff receive regular formal, recorded supervision with their manager to discuss their role and how they are meeting the needs of the residents and identify any training and development needs. All staff have an annual appraisal with their manager. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 21 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, 41, 42 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home. Resident’s views do not underpin all self-monitoring, review and development by the home. Resident’s rights and best interests are safeguarded by the home’s record keeping procedures. Arrangements are sufficient to ensure that the health, safety and welfare of residents are promoted and protected. EVIDENCE: Since the last inspection the previous Deputy Manager has become the Registered Manager. He has several years experience of working with people who have a learning disability and had been the Deputy Manager for several years. He has NVQ level 4 in Management and Care. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 22 Last year the home achieved the ‘Investors in People’ (IIP) Award. From this the Manager completed a development plan for the home on how to move forward and continue to improve the service. The Manager said that the next evaluation of the IIP is due in March 2007 and as part of this staff would be asked for their views on the training and development opportunities they receive. The Manager said that he is planning to develop questionnaires for residents, their relatives and friends and for professionals who work with individual residents. He plans to make these accessible to individuals to ensure that they can be understood. Residents daily records were detailed and written in a way that is nonjudgemental. Records were organised, easily accessible and kept up to date. Fire records showed that staff regularly test the fire equipment to make sure it is working. An engineer regularly services the fire equipment. Regular fire drills are held so that residents and staff know what to do if there is a fire. An electrician completed the five –yearly hard wiring test in 2005 and stated that it was in a satisfactory condition. An electrician tested the portable electrical appliances in October to make sure they are safe to use. A Corgi registered engineer last completed the annual test of the gas equipment in April 2005 so this was overdue. By the end of the visit the Manager had booked this for the following week. A copy of this test was forwarded to the CSCI, which stated that the equipment was in a satisfactory condition. An Environmental Health Officer visited in August and stated that generally the hygiene measures were satisfactory. They said that the temperature of cooked food needs to be tested regularly and the probe must be checked monthly to ensure it is working properly. Since their visit staff have been completing and recording these checks. Staff test the water temperatures weekly to make sure they are not too hot or cold. The recommended safe temperature is 43 degrees centigrade. Records showed that the temperatures are generally maintained between 37 – 43 degrees centigrade. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 23 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 3 27 2 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 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 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 x 2 x 3 3 x Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 24 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. 2. 3. Standard YA20 YA27 YA39 Regulation 13 (2) 16 (2) (j) 23 (2) (b, c) 24 (3) Requirement All medication must be signed for as it is given. The toilet seat in the first floor WC in 78 must be replaced. Timescale for action 16/11/06 31/01/07 The views of the home of 28/02/07 residents, their relatives, friends and other professionals must be sought as part of the quality assurance system. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA19 YA22 Good Practice Recommendations Residents weight records should be regularly monitored to ensure that action is taken if they lose or gain weight quickly. The complaints procedure should be produced in an accessible format to all residents. Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Wheelwright Road, 76-78 DS0000016717.V311796.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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