Care Home: 1 Old Road

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What the care home does well People living at the home see it as their own and are very relaxed in all areas of the home. The environment is warm and welcoming and the home is clean and tidy. There is a low staff turnover and stable staff team. This means that people living at the home have a regular team of staff who have a good understanding of their needs. There are good quality, easy to follow assessments and care plans in place. Any risks to people have been assessed and the assessments are clear and easy to follow. The people living at the home have good positive relationships with staff. People living at the home get on well with each other. People are supported to go out places and are very much part of the local community. Most people go to day or community day service or work for part of the week. For the rest of the time they are supported to stay at home or do other things in the community. The staff are well trained and a majority of them have NVQ (National Vocational Qualification) level 2 or above. Staff have regular support and guidance meetings with their manager. What has improved since the last inspection? People are referred to health and social care professionals when their needs change. The domiciliary care agency that was operated from the care home has been moved to the organisation`s head office. Peoples care plan profiles have been updated. This means staff have full information about people, so they can meet all of their assessed needs and have a greater understanding of them as an individual. The learning disability team will be providing staff with training on personal relationships and sexuality. This means that they can safely inform and support people. There are PRN (as needed) medication plans in place when homely medicines are routinely used for pain management. This means that staff know how and when to safely administer as and when medication. Staff now make sure that they complete peoples` financial records at the time of any transaction. This means mistakes are not made and that peoples` finances are safely managed. What the care home could do better: Staff should continue to develop `life story` books/works with people living at the home, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. `Life history` books should also be developed that include details and photographs of their `history` such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. The recommendations of the speech and language therapy team should be implemented for one person. A number of copies of the `key fobs` and photos for using with the `talking mat` should be produced. This is so that the individual can communicate their feelings, wishes and make them self understood. The menu book needs more photos of plates and bowls of meals so that people can choose and plan what they want to eat. The manager should produce a plan of the changes that will be need to be made to the environment as people get older and frailer and their needs change CARE HOME ADULTS 18-65 Scic - Old Road, 1 1 Old Road Southam Warwickshire CV47 0HD Lead Inspector Jo Johnson Unannounced Inspection 12th August 2008 2.30 Scic - Old Road, 1 DS0000004307.V369776.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 Scic - Old Road, 1 DS0000004307.V369776.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. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scic - Old Road, 1 Address 1 Old Road Southam Warwickshire CV47 0HD 01789 298709 01789 296724 pam@stratfordmencap.org.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) Stratford & District Mencap Mrs Rachael Powell Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Ms Sass achieves the registered Managers Award by 1st September 2006. The home may accommodate one named service user within existing categories over the age of 65 years. 9th November 2007 Date of last inspection Brief Description of the Service: 1 Old Road is a semi-detached house, which provides accommodation for four adults who have learning disabilities. The ground floor has the communal accommodation, with a lounge that leads into a large open plan dining area and kitchen. There is a small utility room off the kitchen. The ground floor also has one bedroom with its en-suite WC and shower. There are three bedrooms on the first floor in addition to a bathroom and staff sleep in room/office. The organisation also operates a domiciliary care agency supporting approximately ten people in the Southam area from the sleep in room/ office. The manager is the registered manager for both the domiciliary care agency and the care home. The house has a rear garden and parking for cars at the front. Shops and village amenities are available locally. The property is owned by a Warwickshire housing association and held on lease by the care provider. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were sent to people who live at the home. The findings of these surveys have been included in the report. This was the home’s first key inspection of 2008/2009. The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 12th August between 2:30 pm and 7:30 pm. On arrival at the home, all of the people who live there and the staff were out. They arrived home at 3:30 pm. The inspection involved; • • Observations of, Makaton signing with and talking with the three people who live at the home and the staff on duty and the manager. Two people were identified for close examination by reading their care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • We would like to thank the people who live at the home, the manager and staff for their hospitality and cooperation during the inspection visit. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? People are referred to health and social care professionals when their needs change. The domiciliary care agency that was operated from the care home has been moved to the organisation’s head office. Peoples care plan profiles have been updated. This means staff have full information about people, so they can meet all of their assessed needs and have a greater understanding of them as an individual. The learning disability team will be providing staff with training on personal relationships and sexuality. This means that they can safely inform and support people. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 7 There are PRN (as needed) medication plans in place when homely medicines are routinely used for pain management. This means that staff know how and when to safely administer as and when medication. Staff now make sure that they complete peoples’ financial records at the time of any transaction. This means mistakes are not made and that peoples’ finances are safely managed. 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. Scic - Old Road, 1 DS0000004307.V369776.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 Scic - Old Road, 1 DS0000004307.V369776.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): 2 Quality in this outcome area is good. People’s needs are assessed and they are provided with information so that they are clear about their rights and entitlements at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide are in large print and supported by pictures, which makes it easier for people with learning disabilities to understand the services in the home. There have been no new people admitted to the home for two years so the outcomes for any new person coming to live in the home could not be assessed. However, there are ongoing and regularly updated assessments in people’s care records that have been amended as their needs have changed so that staff have up to date information about them. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good There is a care planning system in place that gives staff the information they need to meet peoples’ needs. Risk management strategies are in place to meet the assessed and changing needs of the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people’s assessments and care records were seen. Since the last inspection, all of the assessments and care plans have been reviewed as and when people’s needs changed. The information was up to date and was clear and easy to follow. Each section of assessment and care plan had a corresponding risk assessment. Risk assessments have been completed for all aspects of people’s day-to-day lives, activities and areas relating to their health and behaviours. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 11 Each person’s file contained a personal profile. Since the last inspection, these have been updated and now give a full picture of people’s lives and whom they had previously lived with and detail important milestones in their lives since and before moving into the home. Discussions with people and their surveys show that they make decisions about what they do each day. One person who has dementia is finding it more difficult it articulate them self and make their feelings understood. The speech and language therapy team has recently completed a communication assessment and plan. There was a guidance document dated 21st July in the individual’s care records. This referred to using ‘talking mats’ and a ‘key fob’ to assist the person with expressing their feelings and needs. However, the staff member on duty was not aware of the key fob or the new communication guidance. The manager told us following the inspection, that the individual keeps taking things to their bedroom or hiding them due to their dementia. Communication for this individual is vitally important and is only like to deteriorate. This is likely to increase in their frustrations and may escalate some of the behaviours already identified and planned for. The recommendations of the speech and language therapy team must be implemented. A number of copies of the ‘key fobs’ and photos for using with the ‘talking mat’ should be produced; as it is likely that the individual will mislay or take the photos and key fobs. Work has started on people’s ‘life story’ books. These books have photographs and items in them that show what the person has been doing in their lives. However, there has not been much progress since the last inspection on developing these further. The photos seen are now dated so people know when they have done things. The completion of ongoing life story work should be a priority, particularly for the individual who has dementia and the person who does not communicate verbally. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good People participate in a range of social, leisure, and educational and occupational opportunities. People have opportunities to maintain appropriate and fulfilling lifestyles in and outside the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, the day services were closed for their annual summer holiday. People told and signed to us that they had been bowling and had lunch out. From talking, Makaton signing with people and their surveys told us that they can choose how to spend their time during the week and that can do what they want at the weekend. Each person has some planned days at day services or community activities. One person told us “ I’m going to college to do cooking, Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 13 I did it before, I’ve got a chef outfit”. Another person told us “ I’m going to go to college to do art, I still don’t want to go to No 7 (community day services)”. People said that they can have friends and family to visit and they can go and visit friends who live locally. One person has a voluntary job that they have been doing for a number of years. Two of the people living at the home go to the local church both as volunteers and to worship. Daily records looked at showed that during the week activities to meet identified needs support ordinary and meaningful lifestyles. One person has developed a close relationship with another person who is also supported by the organisation. The learning disability team has been supporting the individual’s partner and has recently offered support to the person who lives at the home. The person had commented on their survey, ‘I would like other people not to interfere between me and my girlfriend’. Since then, the individual has decided to accept the support and guidance being offered by the learning disability team. When speaking to them they told us that the “staff are good and help me with things, they don’t interfere”. Staff will now be given some training and guidelines for supporting people with the personal relationships and sexuality from the learning disability team. This was identified at the last inspection and it is positive that this will be happening. The menus show that people are provided with a well-balanced and nutritious diet. All food being stored in the kitchen looked fresh and was well within the use by date. People go food shopping with staff support if they want to. During the inspection, people were sitting with staff planning the menu of the next week. They were using a book with photos of food in it. However, there was a very limited choice of photos of foodstuff, in particular main meals. Both the individual who has dementia and the person who does not communicate verbally were finding it difficult to choose their meals because of the limited choice. This menu book needs more photos of plates and bowls of meals so that people can choose what they want to eat. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good The health and personal care that people in this home receive is based on their individual needs. Medication systems in place are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between staff and the people who live at the home. The staff and manager encouraged and supported people in a relaxed way. People and staff clearly enjoyed each other’s company, smiled, and laughed with each other and staff. Two of the people living in the house said that they like and get on well with the staff. One person signed ‘good’ when talking about staff. There is a gender mix of staff so that peoples’ gender preferences can be met. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 15 People’s health records and care plans showed that their right to good-quality physical and mental health care is being promoted. The records show that as part of promoting their health people make regular visits to a dentist, optician, specific health consultants, their GP and a chiropodist when needed. Two of the people living at the home have significant and changing health needs due to either their dementia and or their ageing. There were clear records of people being referred and being seen by specialist consultants. One person now sees their consultant every month in relation to their dementia. The manager has been a much more proactive in making referrals to both health and social care professionals for people living at the home. People’s weight is recorded and monitored in the interests of maintaining good health. Staff are trained in the medication policies and procedures during induction and there is a medication training programme. There are now medication plans and risk assessments in place for each person. These now included ‘as needed’ plans for homely medication. It is recommended that the person who is able to read and understand their plans should sign them. This is to show that they have been involved and agree with their plans. Medication records seen were correct and the manager actively monitors the completion of the medication records. Any shortfalls have been followed up with individual staff in supervision sessions and a record made of the action required. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good The people who live in this home are able to express their concerns and know whom to speak to if they are unhappy or feel unsafe. They are supported by a staff team who have a good knowledge of how to respond to any suspicion of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People have a copy of the complaints policy, which is in picture, photograph and large print format and includes information about the Commission for Social Care Inspection. This has been reviewed since the last inspection and now includes photographs of the staff in the organisation that people can complain to. We went through the complaints procedure with two of the people and they were able to say or point to whom they would talk to if they were not happy or were worried. There have been no complaints made to us about the home since the last inspection. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 17 The manager went through their complaints and safeguarding referral records. There were a number of complaints and allegations recorded from one person. They have been referred to both the local authority and us as required. The allegations have been investigated and action taken as to what staff are to do in response to any other complaints or allegations from this person. Through both health and social care professional assessments, it has been identified that the allegations may be a response to the individual not being able to articulate and communicate their feelings due to their dementia. The individual has an advocate who overseas all of the allegations and regularly meets with the individual. The manager and staff spoken with were clear that they take all of the allegations seriously and clear records are kept of actions taken. People said they felt safe and would know who to talk to if they were unhappy. The surveys told us that people know who to speak to if they are unhappy and know how to make a complaint. One comment included ‘I use my complaint book as well’. Systems are in place to safeguard the finances of the people living at the home. All three peoples financial records were seen and they balanced with the monies kept in the safe. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good People live in a homely, comfortable and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit, it was homely, comfortable and safe. People living there were able to move around easily and freely and to go to their bedrooms if they chose. The home was clean and free from any offensive odours. The surveys returned shows that the home is ‘always’ fresh and clean. Since the last inspection, there has been ‘chair raisers’ fitted to the lounge furniture so that it easier for people to get out of. A new armchair has been purchased for one person whose mobility is changing. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 19 An occupational therapist has been involved to look at the changing needs of one person as they become more physically frail. They now have a new bed that is easier for them to get out of. The manager should produce a plan of the changes that will be need to be made to the environment as people get older and frailer and their needs change. There are some signs in the kitchen cupboards to show where things need to go. These should be changed for photographs as one person is struggling to always recognise these. People living in the home were happy to show us their bedrooms. The bedrooms reflected their individual lifestyles, interests and tastes. People at the home said that they are involved in cleaning and tidying alongside staff. They said that the staff help them with their laundry. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a very low turnover of staff with only one member of staff leaving since the last inspection. This means that a consistent staff team that they know well supports the people living at the home. There is a photographic staff rota on display in the kitchen so that people know who is on duty when. However, more photographs need to be taken of staff so that there are plenty of spares if they are moved or taken down. The AQAA (Annual Quality Assurance Assessment) and the training chart in the home shows that staff have accessed training in the full range of mandatory, Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 21 health and safety related training, (e.g. first aid, food hygiene and fire safety) as well as specialist care courses, such as dementia and epilepsy. All staff have had an adult protection refresher session with the organisation’s service manager. The manager and staff have been provided with information on the Mental Capacity Act. The two most recently recruited staff records were seen. They included all of the necessary documentation to demonstrate that the staff are suitable to work with people at the home. There were CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks and references for all of the staff. Discussion with staff, the manager and records show that they had regular supervision and staff meetings. Staff spoken with said they had regular supervision and staff meetings. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good People benefit from living in a well run home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for over two years and is registered with us. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 23 The domiciliary care agency that operated from the care home has now moved to the organisation’s head office. The manager spends one day a week working at the head office managing this service. The organisation’s quality assurance system includes formal consultation with families and professionals involved with people. A representative of the organisation carries out monthly monitoring visits and copies of the reports are kept at the home. The reports show that suitable arrangements are in place for monitoring the work of the home and provide an opportunity for the visitor to seek the views of people using the service and to check significant records, such as accidents, incidents and complaints. There are regular house meetings where people can choose how they spend their free time and plan the weekly menus. Information provided by the manager in the AQAA shows that relevant Health and Safety checks and maintenance are being carried out at the home. A sample of Health and Safety records were checked. These records showed that health and safety matters are well managed. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 25 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. 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 Refer to Standard YA6 Good Practice Recommendations Staff should continue to develop ‘life story’ books/works with people living at the home, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. 2 YA6 As people living at the home have changing needs, it is important that ‘life history’ books are also developed that includes details and photographs of their ‘history’ such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. Scic - Old Road, 1 DS0000004307.V369776.R01.S.doc Version 5.2 Page 26 3 YA6 The recommendations of the speech and language therapy team must be implemented. A number of copies of the ‘key fobs’ and photos for using with the ‘talking mat’ should be produced; as it is likely that the individual will mislay or take the photos and key fobs. This is so that the individual can communicate their feelings, wishes and make them self understood. 4 YA17 The menu book needs more photos of plates and bowls of meals so that people can choose and plan what they want to eat. The manager should produce a plan of the changes that will be need to be made to the environment as people get older and frailer and their needs change. 5 YA24 Scic - Old Road, 1 DS0000004307.V369776.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 Scic - Old Road, 1 DS0000004307.V369776.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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