Care Home: 1 Great Wood Road

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What the care home does well This home assesses the needs of the people who live there and produces very good plans to tell staff how people want and need to be enabled to live their lives. There are good details of the action which actions staff need to take to support people in areas such as daily living, personal care, communication and behaviour. The staff make sure that people`s health needs are met by a variety of health professionals. There are very good arrangements for making sure that the staff in hospital know about each person`s needs when they are admitted. The staff make efforts to involve residents in decision-making and participation. They know the preferred ways in which people communicate and encourage them to make choices throughout the day. The staff make sure that people lead full and active lives based on their individual needs and capabilities. People are enabled to attend various activities including day centres, public houses, the cinema, shopping centres, discos and church. Throughout the house there are numerous items such as board games, arts and crafts, DVDs, foot spas and sensory items. People are helped to eat a healthy diet and to try new foods. They choose when and where they eat and their cultural and health needs are met. The home has complaints procedures that are included in the service user guide, on display in each bedroom and are given to relatives who may wish to raise concerns on behalf of their relative. Staff are trained in protecting people from abuse and know the action to take should they suspect that someone has been abused. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. There are enough staff with suitable training so that they can meet the needs of the people they care for. What has improved since the last inspection? There have been improvements in the recording of medication so that people in the home are better protected. There is improved planning and better recording of activities for people in the home. The staff are now receiving better guidance so that they can provide improved support to people whose behaviour challenges staff. There are better systems for making sure that CSCI is notified of incidents. Some improvements to the building and gardens mean that the home is now safer for people who live there. The manager has made good progress on developing a system for monitoring the quality of care so that the she can be sure that the care provided fully meets the needs of the people who live there. What the care home could do better: Some further work is needed to make sure that the quality monitoring system is comprehensive. Further work to the garden could provide a more pleasant space for people to sit out in the warmer weather. Further work is needed to make sure that all staff complete records when creams are applied. The manager has already identified the need for everyone to have a better understanding of person centred planning so that the home can continue to implement best practice and fully meet the needs of all the people who live there. CARE HOME ADULTS 18-65 Great Wood Road, 1 Small Heath Birmingham West Midlands B10 9QE Lead Inspector Chris Lancashire Key Unannounced Inspection 12th August 2008 10:00 Great Wood Road, 1 DS0000016922.V370778.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 Great Wood Road, 1 DS0000016922.V370778.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. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Great Wood Road, 1 Address Small Heath Birmingham West Midlands B10 9QE 0121 773 0017 0121 773 0247 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) Friendship Care and Housing Association Miss Samantha Slater Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 25th June 2007 Brief Description of the Service: 1 Great Wood Road is a two storey home offering ground floor accommodation to service users, with the top floor being used for office space. The home caters for 4 service users with learning disabilities and diverse needs, some experiencing mobility difficulties. All service users have their own individualised bedroom. There is a car park to both the front and rear of the property. To the front is a small garden and planted area equipped with seating. The service user guide states that fees are from £332.97 per week. Fees are negotiated on an individual basis dependent on the service users’ needs. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We inspected this home on a weekday, without giving any notice that we would be visiting. We spoke with the manager and three members of staff and met all three of the people who live there. We also looked round the home and garden. The manager showed us records relating to the running of the home, the care of the people who live there, the staff and the safety of the building. The manager had also completed a questionnaire (AQAA) providing details about the home. We used the information which we gathered to form judgements about how well the home is meeting the needs of the people who live there. The quality rating for this service is 3 stars. This means that the people who use this service experience excellent quality outcomes. What the service does well: This home assesses the needs of the people who live there and produces very good plans to tell staff how people want and need to be enabled to live their lives. There are good details of the action which actions staff need to take to support people in areas such as daily living, personal care, communication and behaviour. The staff make sure that people’s health needs are met by a variety of health professionals. There are very good arrangements for making sure that the staff in hospital know about each person’s needs when they are admitted. The staff make efforts to involve residents in decision-making and participation. They know the preferred ways in which people communicate and encourage them to make choices throughout the day. The staff make sure that people lead full and active lives based on their individual needs and capabilities. People are enabled to attend various activities including day centres, public houses, the cinema, shopping centres, discos and church. Throughout the house there are numerous items such as board games, arts and crafts, DVDs, foot spas and sensory items. People are helped to eat a healthy diet and to try new foods. They choose when and where they eat and their cultural and health needs are met. The home has complaints procedures that are included in the service user guide, on display in each bedroom and are given to relatives who may wish to raise concerns on behalf of their relative. Staff are trained in protecting people from abuse and know the action to take should they suspect that someone has been abused. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 6 The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment, which encourages independence. There are enough staff with suitable training so that they can meet the needs of the people they care for. What has improved since the last inspection? What they could do better: Some further work is needed to make sure that the quality monitoring system is comprehensive. Further work to the garden could provide a more pleasant space for people to sit out in the warmer weather. Further work is needed to make sure that all staff complete records when creams are applied. The manager has already identified the need for everyone to have a better understanding of person centred planning so that the home can continue to implement best practice and fully meet the needs of all the people who live there. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 7 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. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in the outcome area is good. People considering this home have the information available they need to make an informed choice about where they live. The assessment procedure ensures that staff know individuals’ needs and they are assured that the home can meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new admissions to the home for several years; however, we saw that the home’s admission policies and procedures confirm that people considering moving into this home would have their needs assessed appropriately in order that the home can be confident of meeting them. The home does not consider emergency placements and this is made clear in the Statement of Purpose. The manager explained that careful consideration would be given to making sure that anyone admitted would be able to fit in with the people already living there. We sampled the records of people living at the home and found they contained copies of the placing authorities’ initial assessment and contract. The manager explained that information such as the service user guide, which has pictures to help people to understand it, is kept in each person’s bedroom along with Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 10 other information about the home in order that information is accessible to people and their families. The manager told us that these guides are being reviewed and updated. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is good. People living in this home are involved in decisions about their lives, and play an active role in planning the care and support they receive. They are supported to take appropriate risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us before the inspection that everyone who lives there requires help with personal care, communication and health care management and that people also have physical needs. She also told us that all have up to date care plans that describe the support required in these areas, including restrictions and longer term objectives and that all plans have been reviewed in the last 12 months with involvement of social workers or care managers. There was a meeting with a social worker to review one person’s care on the day of the inspection. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 12 We looked at the support plans for people in the home and found that they contain very detailed instructions of the actions staff need to take to support people in areas such as daily living, personal care, kitchen, eating, housekeeping, travelling, communication, social, relationships, mobility, finances, support during the night and behaviour. We saw simple, clear instructions such as ‘If I am not going to the centre, I prefer to stay in bed for a bit and have a cup of tea’. We saw that key workers complete monthly reviews and then change the plans if necessary. Where possible the home encourages families to be involved in drawing up care plans to support people with communication difficulties. The manager explained that great efforts have been made to find suitable advocates for people who do not have anyone to carry out this role. We saw letters which confirmed this, saying that there are no suitable advocates at present, but that one would be made available should there be an emergency. The people living in this home have their own methods of communication, some of which involve elements of formal systems. We saw that staff are good at knowing how each person makes their wishes and choices known. They use a variety of methods such as the use of large, colourful photographs and pictures so that they can make choices about activities and meals. We saw staff communicating well with people, for example, one person who wanted a drink. We also saw that staff were preparing people for what would happen next by showing them pictures. This helped to reduce the element of surprise and had a calming effect. We saw risk assessments which contained details of how people could be helped to be as independent as possible and the measures which needed to be put in place to make sure that they would be as safe as possible. The manager and staff gave us examples of progress which people had made in developing skills. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 13 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, 13,14,15,16 and 17. Quality in this outcome area is good. The people who live in this home are helped to develop their skills and relationships in the home and community and to follow interests of their choice. They are provided with a healthy diet which suits their needs and preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw records which are used to monitor when people take part in a variety of activities based on their individual needs and capabilities. These include day centres, public houses, the cinema, shopping centres, discos, bowling, floor exercises and social centres. People are also helped to attend church if they have chosen to do so. They go on holidays. Throughout the house there are Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 14 numerous items such as board games, arts and crafts, DVDs, foot spas and sensory items. During the inspection, one person was helped to bake a cake. The manager told us that the staff support people to maintain contact with families and friends. We saw lots of examples of visits made by people’s families and some are involved in and consulted about most aspects of the care. For example, one family helps to provide guidance to staff about meeting cultural and religious needs. There are no set menus as there is daily choice about what people would like to eat. We saw a folder which has details of what each person likes and dislikes. It also has ideas of what they may like to try. There are photos of different types of food and of people living in the home eating, coking and washing up. The cultural and religious needs of people living at the home are respected and suitable arrangements have been made to meet these. The staff are aware of the principles of healthy eating and they keep good records of what people have eaten. Great Wood Road, 1 DS0000016922.V370778.R01.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, 20 and 21. Quality in this outcome area is excellent. The people who live in this home receive support and care in the way they prefer and need at all times in their lives. Their health needs are met and they are protected by the home’s policies and practices regarding medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw and heard staff seeking permission to enter residents’ bedrooms before entering, talking to individuals in a friendly and respectful manner and offering assistance with personal care discreetly. Sampled records showed that care is provided in the ways indicated in the plans. The health needs of each person are recorded in their health action plans. People’s health is monitored and recorded. There are records of people’s weight. We saw that people had been visited by a variety of healthcare professionals and had been to appointments at hospitals and other health venues. On each person’s file we saw a document which they would take with them if they were admitted to hospital. It shows how they would want to be cared for and supported by the hospital staff. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 16 The staff help to communicate with health professionals and the manager told us that the home has been successful in assisting one person to have some medication withdrawn. An excellent level of support had been provided to a person living at the home who was terminally ill. Supported was provided through the illness and the family’s wishes for them to remain at the home in familiar circumstances until they died were respected. The staff at the home also enabled other people living there to attend the funeral and provide continuing contact with the family and support to other people living at the home. This period clearly had a deep effect on staff and people living in the home and demonstrated how well the staff worked together for the benefit of the person concerned and their family. The home uses a monitored dosage medication system with each person’s medication stored in secure facilities in their bedrooms. There are policies and procedures for self-medication, obtaining medications, administration, recording, disposal, homely remedies and training of staff. Competency assessments are completed for all staff who administer medication. We saw that medication records for tablets and liquids were up to date and appropriately completed. However, we saw some gaps in the administration records for creams. The manager told us that agency staff do not always sign for creams. The staff meeting records show that she is already aware of this and is taking action to make sure that all applications are recorded. Great Wood Road, 1 DS0000016922.V370778.R01.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. People who live in this home are protected from abuse, neglect and self harm and their views are listened to and acted on. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us that people living at the home are supported to raise concerns. The home has a complaints procedure that is included in the service user guide, on display in each bedroom and given to relatives who may wish to raise concerns on behalf of someone living in the home. There have been no complaints about this home during the past year. The company complaints procedure has been used effectively by the manager to complain about the central heating on behalf of the people in the home. We saw that there is a copy of Birmingham City Council’s multi agency protection procedures in the home along with the home’s policy on the protection of vulnerable adults. The home’s policy is very detailed and informative. The organisation has recently reviewed and updated its policy in respect of the protection of vulnerable adults and the manger supplied us with a copy of this. Staff receive training in recognising the possible signs and symptoms of abuse. The home operates a ‘no restraint’ policy in respect of physical intervention. There are instances where the behaviour of people in the home has challenged staff and where staff have had anxiety about how to handle the situation and Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 18 avoid injury to themselves or the person concerned. The manager has recognised this and sought the advice of a specialist in this area. A professional from BILD is providing support to the staff team to look at ways of interacting with people with autism. Staff have received further training in handling violence and aggression and are now using new methods to try to minimise the incidents of this behaviour. These include using pictures and objects to help to prepare each person for events, such as bathing, which may have caused them to become agitated in the past. We saw that there are policies and procedures, secure facilities and a suitable recording system for managing money on behalf of people living in the home. We checked the balances of the money held for the three people and found them to be correct. This means that people are protected from financial abuse. Great Wood Road, 1 DS0000016922.V370778.R01.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): Quality in this outcome area is good. 24 and 30 The people in this home live in a homely, safe and comfortable environment, which is clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This home is purpose built. The accommodation for the people who live there is on the ground floor. There is an open plan, spacious communal area with adequate space for aids and adaptations, specialist bathrooms which meet people’s needs and individual bedrooms that are well decorated according to people’s tastes. All areas used by the people who live in the home are in a good state of repair and decoration. However, the stairway to the office and staff sleeping room looks shabby and the paint has worn off in an uneven way. The area would Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 20 benefit from being painted and this would create a more pleasant environment for staff and professional visitors to the home. The garden is fenced to offer some privacy for users. There are raised beds and seating. However, due to the growth of tree roots, there are uneven areas which are especially noticeable where the garden bench is now at an angle and may not be safe to use. There is also an area which was created to house the washing line. This is no longer used and the space could be used to enhance the facilities for people living in the home. The manager told us that she plans to improve the garden by creating a new patio area outside the kitchen window, with chairs and a table. During the inspection there were no offensive odours and the home presented as homely and clean. Staff have received training on the prevention of infection and management of infection control. The home has a small laundry that contains all appropriate equipment including personal protective clothing. Staff follow procedures to minimise the risks of cross contamination and we saw them wearing gloves and aprons at appropriate times. Great Wood Road, 1 DS0000016922.V370778.R01.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. The people who live in this home have their needs met by a competent team of staff who receive suitable training. They are protected by the home’s recruitment policy and practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager told us in the AQAA that 372 staff hours were used the week it was completed. There are 8 permanent staff and 10 bank staff available for use and this seems to be enough to meet the needs of the people who live there. On the day of the inspection, the manager was in a review meeting when we arrived. When she came to meet us, she telephoned for an extra member of staff so that there could be enough staff to assist us as well as support the people in the home. The person arrived later in the morning. This showed that extra staff could be obtained quickly if needed. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 22 45 of the permanent staff are qualified to NVQ level 2 or above and a further 45 are being trained. In addition the records show that staff have undertaken training in a range of areas relevant to their role. Training is Learning Disability Award Framework accredited. The home also uses the services of other professionals to provide staff with training such as the recent support provided for handling behaviour which challenged staff. We saw records for recently recruited staff. These showed that they receive regular supervision and undertake the company’s induction programme. We sampled the records of three members of staff in order to assess the home’s recruitment and selection practices. They contained references and evidence of checks through the Criminal Records Bureau to ensure people living at the home are safeguarded from harm or abuse. Great Wood Road, 1 DS0000016922.V370778.R01.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. The people who live in this home are protected by the arrangements for managing the home, monitoring the quality of care and checking equipment, so that their health, safety and welfare are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of this home is appropriately experienced. She expects to complete NVQ level 4 by November 2008. She demonstrated many areas of good practice and showed that she can identify areas where improvement is possible. Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 24 The manager told us that the company is working to develop a comprehensive and robust system for quality monitoring. This is on the agenda at managers’ meetings as a monthly update/action item. In this home there are questionnaires for people in the home, their representatives and professional visitors and a variety of audit forms including a monthly health and safety checklist, night staff audit form and opportunity plan audit. We discussed this with the manager and her manager. Further work is planned to formalise the system. We saw evidence that the manager reacts to feedback from people living in the home and makes changes in response to this. For example, it was noted that one person had not really enjoyed her holiday, so more research was being undertaken to look at alternatives which she may prefer. We also saw the reports of monthly visits made under Regulation 26, by a representative of the organisation and these provide further monitoring of the quality of care. The manager notifies the CSCI when incidents occur, in line with Regulation 37 of the Care Home Regulations 2001. The latest guidance for reporting under this regulation is on the office wall. The manager told us that the company is using an external company to review and update many of its policies and procedures. The manager informed us that portable equipment, hoists, fire detection and equipment, heating system and gas appliances have all been serviced in the past twelve months. We sampled records and found this to be the case. There is secure storage for products which may cause harm and a folder with relevant risk assessments. Great Wood Road, 1 DS0000016922.V370778.R01.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 3 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 4 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 4 3 X 3 X X 3 x Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. YA6 Refer to Standard Good Practice Recommendations Continue to seek advocacy services for those individuals who have communication difficulties in order that their views and opinions are obtained when planning their care and support. Make sure that staff always complete the records when creams are applied. Decorate the stairwell leading to the office and staff sleeping room. Develop the garden area so that it is a more pleasant place for people to sit in. Continue to develop the quality assurance system so that it is robust and comprehensive. 2 3 4 5 YA20 YA24 YA24 YA39 Great Wood Road, 1 DS0000016922.V370778.R01.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 Great Wood Road, 1 DS0000016922.V370778.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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