Care Home: Boldmere Drive

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What the care home does well People`s strengths and needs are properly assessed, to make sure they get the care they need. Their care plans are detailed, so that staff are clear about how people like to be supported. Plans are reviewed regularly, to make sure that they are kept up to date. Staff help people to do the things that they value and enjoy. Residents are supported to keep in touch with people that are important to them. They are able to be a part of their local community and to do things around the house, according to their individual wishes and abilities. They get good basic personal care and support to keep medical appointments and specialist healthcare, according to what they need. People are encouraged to eat healthily and to enjoy their food. All of these things are done to help them stay healthy and well. People enjoy living in a comfortable house that is homely and welcoming. Many of the staff have worked there a long time, so people know each other well and staff have a good understanding of how residents like to be cared for. The home is well run and the Manager has a positive attitude to developing the service for the benefit of the people who use it. People feel that they can speak up if they are concerned about anything, and are confident that what they say is listened to and taken seriously. What has improved since the last inspection? (Not applicable: new registration) What the care home could do better: People`s care plans could be improved by developing the use of person-centred approaches. This will help to make sure that the individual concerned is the focus of everything considered. Each month staff write a report showing how residents` plans have been reviewed. It is suggested that these reports should include people`s goals, so that it is possible to see whether or not these are being met. Making goals clearer will help to show whether or not they are working. Health action plans (like general care plans) should include clear goals, to make sure that everything that might help people keep healthy and well is being done when it should. Staff should have training that relates specifically to the needs of the people they support. It would be good to develop their skills in the use of personcentred approaches. Training about working with people who have autism would also help to develop their knowledge about the needs of the residents. Arrangements for staff to have formal supervision need to improve, to make sure that they have all the support they need to do their jobs well. It is anticipated that this will be addressed in the near future. CARE HOME ADULTS 18-65 Boldmere Drive Sutton Coldfield West Midlands B73 5ES Lead Inspector Gerard Hammond Unannounced Inspection 17th March 2009 09:30 Boldmere Drive DS0000072766.V374772.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 Boldmere Drive DS0000072766.V374772.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. Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boldmere Drive Address Sutton Coldfield West Midlands B73 5ES 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) 0121 386 1384 0121 386 1384 Midland Heart Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - code PC; to service users of either gender; whose primary care need on admission to the home are within the following category: - Learning Disability - LD 4 The maximum number of service users to be accommodated is: 4. 2. Date of last inspection New registration Brief Description of the Service: 3 Boldmere Drive is a scheme run by Midland Heart offering accommodation, care and support for four people with learning disabilities and complex support needs. The house is a large traditional style property located in a residential area of Sutton Coldfield. Boldmere Drive is close by Boldmere village and Wylde Green. The area is well served by public transport and offers easy access to a wide range of community facilities and local amenities, including shops, places to eat, pubs, cinema, parks, and places of worship. Residents each have their own single rooms with wash hand basins: one room has en-suite facilities. Accommodation is spacious and well furnished, and residents enjoy access to a secure and private garden. The house is staffed around the clock and sleep-in cover is provided during the night. There is limited off-road parking at the front of the house. The service should be contacted directly for information about current fees. Boldmere Drive DS0000072766.V374772.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. This is the home’s first key inspection of the current year 2008-9, following the service’s registration under the Midland Heart name. We gathered information from a number of places to inform the judgements made in this report. The Manager sent us a completed Annual Quality Assurance Assessment (AQAA) before the inspection began. This is a self-assessment that focuses on the outcomes for people who use the service, and provides us with some numerical information about it. We also looked at reports from the Registered Provider, incident reports, and inspection reports from the services previous registration. We made a visit to the home and were able to meet all of the residents and look around the house. However, it was not always possible to seek people’s views directly, due to their communication support needs and learning disabilities. We met with the Manager and members of the staff team on duty. We looked at written records including personal files, care plans, staff files, safety records and other documents. We were able to see staff supporting and interacting with the residents. Thanks are due to the residents and staff team for their help and support throughout the inspection process. What the service does well: People’s strengths and needs are properly assessed, to make sure they get the care they need. Their care plans are detailed, so that staff are clear about how people like to be supported. Plans are reviewed regularly, to make sure that they are kept up to date. Staff help people to do the things that they value and enjoy. Residents are supported to keep in touch with people that are important to them. They are able to be a part of their local community and to do things around the house, according to their individual wishes and abilities. They get good basic personal care and support to keep medical appointments and specialist healthcare, according to what they need. People are encouraged to eat healthily and to enjoy their food. All of these things are done to help them stay healthy and well. People enjoy living in a comfortable house that is homely and welcoming. Many of the staff have worked there a long time, so people know each other well and staff have a good understanding of how residents like to be cared for. The home is well run and the Manager has a positive attitude to developing the service for the benefit of the people who use it. People feel that they can speak Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 6 up if they are concerned about anything, and are confident that what they say is listened to and taken seriously. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Boldmere Drive DS0000072766.V374772.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 Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed, so that their care and support can be properly planned. EVIDENCE: The home at 3 Boldmere Drive is now registered as part of the Midland Heart group of services. The people living there are the same individuals who were resident under the home’s previous registration. This group of people has lived at the house for a number of years, and there are currently no vacancies. We looked at people’s personal files to see if their needs had been properly assessed. Their records contained detailed assessments of their support needs, and we saw that these had been kept under review. This means that important information to guide the planning of people’s care and support is in place as required, and kept up to date. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have detailed care plans, to make sure they get the support they need in ways they like, and to keep them safe. Staff support them to make choices and decisions, so as to encourage their independence. EVIDENCE: We looked at people’s records to see how their care and support are planned and managed. Their personal files included detailed care plans, so that staff have the information they need to give people support in the ways that suit them best. The people living in this house have high-level complex support needs. Most of the staff team have worked at the home for a good number of years, so they have had the opportunity to get to know each other well. Residents’ care plans include detailed guidance about their preferred routines. When we talked to staff it was clear that they knew what these were, and why it is important that they are followed. Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 10 Each person has a named key worker. This staff member has responsibility for completing a written report each month. This helps to ensure that care plans are reviewed constantly, so that information can be kept fully up to date, and any issues or concerns dealt with quickly. Care plans were supported with risk assessments, which had also been kept under review. This shows that important information about how to support people to stay safe is included in their care plans. During the visit to the home, we saw staff supporting people to make decisions and choices about things they wanted to do. The capacity to do this is restricted, to a greater or lesser extent, by each individual’s level of learning disability. However, staff work hard to encourage people to be as independent as they are able. We saw them asking residents about going out and choosing activities, making decisions about what they wanted to eat and drink, and if they wanted support to take a bath. Previous reports show that residents are encouraged to do things around the house, such as setting and clearing the table, washing up, looking after their rooms, watering the plants, and so on. We talked with the Manager about care planning and management. It was suggested that this could be improved by ensuring that people’s goals had outcomes that can be clearly measured. It should be possible to evaluate these as part of the existing monthly reporting system. Doing this would help to ensure that people get the support they need to achieve the things that are really important to them. Further development of the use of person-centred approaches could enhance this further. However, the good work already being done by the staff team to support the people in their care should be acknowledged: these recommendations are made as matters of good practice. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able go to places they like, and to do the things that they like that are important to them. They are able to make use of local facilities, ensuring that they have a real presence in their local community. They get the support they need to make sure that they can stay in touch with people who mean a lot to them. They are able to make positive choices about the food they eat, so that they enjoy their meals and have a balanced diet. EVIDENCE: We saw that people living at Boldmere Drive are able to do activities that they value and enjoy on a regular basis. Three of the residents have placements at local day centres, which they have attended for many years. The familiarity of these routines is very important to them. The other resident has a homebased programme. She is able to go out with staff every day, if she so chooses. This approach is judged to be more suitable, and takes account of her assessed needs and her time of life. All of the residents have a specific day in Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 12 the week when they are at home. On this day they are particularly encouraged to do things that will maintain or develop their independence skills. This might involve doing jobs around the house or going out into the community with a member of staff. The records we looked at showed us that people were supported to go to the cinema, go shopping, use local cafes, restaurants and pubs, go out for walks, visit the theatre, go to the park and out on day trips. One of the residents told us she had been bowling that afternoon. She showed us her scorecard and said she had enjoyed it very much. Residents get the support they need to keep in touch with the people who are important to them. Their records provided evidence of contacts with family members including visits, letters, phone calls and going to stay. One resident, whose next of kin lives a good distance away, has a friend whom he sees regularly. He also has contact with a visiting service provided by Mencap, a well-known organisation for people with learning disabilities and their families. We saw that another resident had a visit from her sister during the time we were at the home. We looked at the stocks of food kept in the home, and saw that these were plentiful. These included fresh fruit and vegetables. We saw the record of what people had had each mealtime. This showed us that residents enjoy a varied and balanced diet. Their personal records include a healthy eating plan. Residents are directly involved in shopping for their food, so that they can choose the things they like, with support. One of the files we looked at showed that the person concerned likes to prepare his own lunch to take to the day centre. The home has a “rolling menu” based on the known preferences of the residents. The small number of people living in the house means that it is always possible to offer alternatives. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are well cared for by staff that know them well, so that they are supported in ways they like. They get the help they need to stay well and healthy. Proper arrangements are in place to make sure that they get their medicines at the right time and in the correct amounts. EVIDENCE: We were able to meet all of the residents on the day we visited the home. We saw that they were all dressed in clean, good quality clothing and had clearly received the help they needed with their personal care and hygiene. We saw that staff treated them with respect, warmth and friendliness. As reported above, most of the staff have worked at the home for a number of years, so they know the residents well. They are familiar with the ways people like to be supported. Residents and staff appear to get on well with each other and are clearly comfortable in each other’s company. Looking at people’s personal records showed us that they get the support they need to stay healthy and well. Residents’ weights are monitored regularly each Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 14 week. Prompt action has been taken to refer people to health professionals as required, to make sure they get the advice, support and treatment they need. Records we saw showed the involvement of GP, Community Nurse, Psychiatrist, Dentist, Optician, Speech and Language Therapist, and Dietician in people’s care. Each person has a healthy eating plan. Everyone also has a Health Action Plan. We talked to the Manager about how these might be developed by setting some clear goals and evaluating them regularly. This is to try and make people’s healthcare proactive, rather than reactive. This means that the focus is on doing things that actively promote good health, rather than just reacting when problems arise. However, it should be acknowledged that residents are well supported in this area. The recommendation is made merely as a matter of extending existing good practice. None of the residents is able to manage his or her medication. The home uses the Boots MDS (monitored dosage system). We checked the medication administration record (MAR). This had been completed, and medicines given as recorded. The medication file included information about all prescribed medicines, and protocols (clear guidance) for PRN (“as required”) medication. Stocks of medicines are audited regularly, and copies of prescriptions held with the records. Two staff check and sign for medication each time it is given. This represents good practice and helps to ensure the risk of error is kept to a minimum. The medication store was clean, tidy and secure. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns are taken seriously. The support they receive ensures that they are protected from harm. EVIDENCE: We have not received any complaints in respect of this service. The home has appropriate complaints and adult protection policies as required. It has to be acknowledged that the complex support needs, levels of learning disability and communication support needs of the people living in this house mean that these documents have little relevance for them individually. Staff are familiar with people’s ways and able to pick up on changes in behaviour, demeanour, “body language” and so on as indicators that something may be amiss or that people are unhappy. They understand the importance of people’s routines and rituals in helping them feel comfortable and secure. As previously reported, the Manager uses the relatives and advocates meetings to reinforce the complaints procedures and highlight the processes for raising any concerns on residents’ behalf. All staff have received training in the protection of vulnerable adults from abuse. Staff records show that checks have been carried out with the Criminal records Bureau. This is to ensure that people employed at the home are suitable to work with vulnerable adults. No safeguarding referrals have been received. Three residents’ personal finances are administered through the Local Authority’s Appointeeship Unit and the home keeps detailed financial Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 16 records of all transactions. The other person has a relative who manages his money on his behalf, in close liaison with the local bank and the home, ensuring he has access to funds when he needs them. We sample checked the cash held in the office safe on residents’ behalf. The amounts held tallied with the record and receipts as appropriate. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house is comfortable, clean and well maintained so that residents are able to enjoy living in a safe and homely environment. EVIDENCE: We looked around the home in the company of the Manager. The house is a large domestic scale property: it is generally well furnished, decorated and maintained throughout. It is in keeping with all the other houses in the neighbourhood. The kitchen has been refitted and new carpets laid in the hall and dining room in the last year. Bedrooms are all very individual, according to each person’s tastes and preferences. Rooms are comfortably furnished and decorated. We saw pictures, photographs, ornaments and personal possessions in all of the rooms. One resident has en-suite facilities in her room, and there are ample Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 18 bathing and toilet facilities in the house for the residents to use, according to their needs and wishes. The shared spaces in the house include a comfortable lounge and a separate dining room. Both are decorated and furnished to a very good standard, and well used by the residents. There is an enclosed private garden at the rear of the house for people to enjoy when the weather permits. The Manager told us that a complete new central heating system is going to be installed in the near future. Staff work hard to make sure that the house is fresh, clean and tidy. This means that the residents at 3 Boldmere Drive can enjoy living in a comfortable safe and homely environment. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care team is consistent and well qualified, so that residents benefit from being cared for by competent staff that know them well. Some improvements to training and supervision will ensure that staff have all the knowledge and skills and support they need to do their jobs well. EVIDENCE: We met with the staff on duty and looked at the records of the staff team. All of the staff currently working at the home have been there for over twelve months, most of them for several years. The residents’ support needs mean that continuity of care is especially important to them. Records show that staff have a good understanding of the people in their care, that they are sensitive to the importance of consistent handling and respectful of people’s routines, habits and behaviour patterns. We watched staff interacting with residents, and conversations with them show that this remains true. Positive feedback from people’s relatives about the competence of the staff in providing care continues to reinforce this. Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 20 Staff records are well organised and presented. We saw that files contained completed application forms, written references and evidence of checks with the Criminal Records Bureau, as required. This shows that care is taken to make sure that people employed to work in the home are fit for the job. The information provided by the Manager in the Annual Quality Assurance Assessment (AQAA) shows us that the staff team is well qualified. Records provided evidence of recent training, and staff confirmed that they have regular training opportunities and updates. Midland Heart is in the process of re-organising staff training, which is dealt with centrally. The first priority has been training relating to health and safety. A spreadsheet showing what training individuals have done and identifying dates for “refreshers” is now in place. This should be extended to cover all other training in due course. It is recommended that service specific training in person-centred planning and also working with people with autism, be made available to all the staff at the home. We noticed that formal staff supervision is not currently up to standard (i.e. minimum of six times in any twelve-month period, pro rata for part-time staff). It has to be acknowledged however that there was a gap between the previous manager leaving and the current one starting. Also, that the new Manager has had to balance priorities since coming into post. The small size of the home means that staff are in regular contact and issues tend to be dealt with as they arise. Staff said that they felt well supported. Staff group meetings have taken place at regular intervals. It is anticipated that the shortfall in relation to formal supervision will be addressed in due course. Boldmere Drive DS0000072766.V374772.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is generally well run for the benefit of the people who use it. Clear efforts are made to find out what residents feel about the quality of the service they receive so as to meet their needs and wishes. Important safety checks are carried out regularly to make sure that people living and working in the home can stay safe. EVIDENCE: We talked with the new Manager, who came into post in recent months. She has worked at the home in the past, so she already knew some of the residents. She is appropriately qualified and has several years experience of working in this field. Her application to become formally registered as the Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 22 Home manager is in progress. Staff told us that she is approachable and that they are comfortable raising any matters of concern with her. The organisation has systems in place for monitoring and quality assurance of the service. Visits and reports required under Regulation 26 (Care Homes Regulations 2001) are carried out regularly. The home is reviewed under the SQS (Service Quality Scheme) each year: we saw copies of questionnaires relating to this on residents’ personal files. Monthly meetings with key workers and regular meetings with relatives and advocates provide further opportunities for consultation with residents and their families. We sampled safety records. These showed us that important fire safety equipment has been serviced and checked regularly. One of the residents plays an active part in weekly “housekeeping checks” to make sure that good practice around the home is maintained. The organisation now has a dedicated Health and Safety team, and carries out an annual audit. We saw that cleaning materials and other potentially harmful substances were stored securely. Boldmere Drive DS0000072766.V374772.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 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 3 27 3 28 3 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 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 3 3 3 x 3 3 3 X X 3 X Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 Develop the use of person centred approaches and set goals with outcomes that can be clearly measured. This is to ensure that people get the support they need to achieve the things that are most important to them. Further develop health action plans in order to promote people’s health and wellbeing more proactively. Provide staff with training in person-centred planning, and working with people with autism. This is to develop their knowledge and skills, to help them do their jobs well Improve arrangements for staff to receive formal supervision (minimum of six times in twelve-month period, pro rata for part-time staff). This is to ensure that they get the support they need to do their jobs well. 2. 3. 4. YA19 YA35 YA36 Boldmere Drive DS0000072766.V374772.R01.S.doc Version 5.2 Page 25 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. 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