Care Home: Shirwin Court

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What the care home does well The home ensures that good assessments are carried out to ensure that they are able to meet the needs of people prior to their admission. Care plans are generated from the initial assessment. They are comprehensive and detail how an individual wishes their needs to be met. Medication administration, storage and disposal are in accordance with accepted good practice. All staff are trained in the safe handling of medication.People are encouraged to make choices about their daily lives, this was reiterated by people telling us about their positive personal experiences of living at home. There is an accessible complaints procedure in place, which people are made aware of through good information provided to them before moving into the home. The environment that people live in is clean and comfortable and offers a homely atmosphere. Staff receive training to ensure they have the knowledge and skills to deliver good quality care. Staff are supervised and their practice monitored to ensure that this standard of care is maintained. The home has a qualified manager who ensures the ethos of the home is open and transparent for people living at the service, their family/representatives and staff working at the home. People who use the service are listened to and their views are gained through surveys, informal discussions and meetings. What has improved since the last inspection? What the care home could do better: There were no requirements made as a result of this inspection. However two recommendations remain in place as follows. It is recommended that the call system be replaced with one that has to be cancelled within the residents` bedrooms. Bedroom door locks must allow the resident to lock the door when they are not in the room to keep their valuables safe. CARE HOMES FOR OLDER PEOPLE Shirwin Court 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES Lead Inspector Karen Powell Key Unannounced Inspection 29th July 2008 10:45 X10015.doc Version 1.40 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 Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirwin Court Address 46 Poplar Avenue Edgbaston Birmingham West Midlands B17 8ES 0121 420 2398 0121 686 3727 shirwincourt@yahoo.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Rahmatullah Hissaund Mrs Bibi Hissaund Mr Rahmatullah Hissaund Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is able to accommodate ten people by reason of old age of which eight may have mild Dementia. No residents with Dementia are to be admitted to the second floor accommodation. Date of last inspection Brief Description of the Service: Shirwin Court is a privately owned double fronted property that has three floors. The home offers accommodation for 10 older people. The home is situated in Edgbaston close to the Hagley road. From the Hagley road there is public transport available to the centre of Birmingham. Local shops and other amenities are available within walking distance to Bearwood shopping area. The home has 6 single and 2 double bedrooms that are located on all three floors. There are stair lifts between each floor. The top flight of stairs is steep and narrow and can only be negotiated by mobile residents. Communal toilet and bathing facilities are available on the ground and first floors. The second floor bedrooms have toilets but the en suite showers are not useable as they cannot be restricted to 43 degrees Centigrade. One of the bathrooms has an in-bath lift for assisted bathing. Not all toilets are large enough for staff to offer assistance. The home has a large well-furnished lounge that overlooks a pleasant garden with shrubs, patio and garden furniture. The separate dining room is used by residents for activities as well as for meals. The home has a ramp and handrails to the front door. Parking is only available on the road. Fees range between £345.41 and £359.98 per week. The fees are published in the service user guide. There are additional charges for, hair dressers, toiletries and magazines and newspapers; the cost of these varies with personal preference. The home will arrange a chiropodist at a cost of £8.00 per session. People who use the agency and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 5 Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people who use this service experience Good quality outcomes. The inspection was unannounced and took place on 29th July 2008 by one inspector over four hours. A range of evidence was used to make judgements about this service to include discussions with people who use the service, the registered manager, staff on duty, a tour of the home, and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of four people, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. Some of the manager’s comments have been included within this inspection report. The purpose of the inspection was to assess all ‘Key’ National Minimum Standards for older people and any additional Standards considered necessary. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home ensures that good assessments are carried out to ensure that they are able to meet the needs of people prior to their admission. Care plans are generated from the initial assessment. They are comprehensive and detail how an individual wishes their needs to be met. Medication administration, storage and disposal are in accordance with accepted good practice. All staff are trained in the safe handling of medication. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 7 People are encouraged to make choices about their daily lives, this was reiterated by people telling us about their positive personal experiences of living at home. There is an accessible complaints procedure in place, which people are made aware of through good information provided to them before moving into the home. The environment that people live in is clean and comfortable and offers a homely atmosphere. Staff receive training to ensure they have the knowledge and skills to deliver good quality care. Staff are supervised and their practice monitored to ensure that this standard of care is maintained. The home has a qualified manager who ensures the ethos of the home is open and transparent for people living at the service, their family/representatives and staff working at the home. People who use the service are listened to and their views are gained through surveys, informal discussions and meetings. What has improved since the last inspection? What they could do better: Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 8 There were no requirements made as a result of this inspection. However two recommendations remain in place as follows. It is recommended that the call system be replaced with one that has to be cancelled within the residents’ bedrooms. Bedroom door locks must allow the resident to lock the door when they are not in the room to keep their valuables safe. 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. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at a file of the most recent person admitted to the home. The individuals family arranged for their relative to spend the day at the home before making a decision about moving in on a permanent basis. We found that a comprehensive assessment of the individuals needs had been carried out by the home at this trial visit. An assessment had also been carried out by the local authority who were supporting the individual through the care Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 11 management process and a copy of the local authority care plan had been obtained by the homes manager before the individual was admitted. Through discussion with the registered manager and examination of the assessment documentation it is clear that time and effort is put into planning the admission to make the experience personal to the individual. The individual concerned told us they were happy with the arrangements made and that they are being helped by staff to settle in. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. Peoples health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. Medication is managed effectively and in accordance with good practice. Peoples right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was stated on the AQAA that the home compiles care plans that the home ensures residents have individual care plans to meet their needs and have healthcare needs met. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 13 We looked at two care plans in detail. One of an individual who had recently moved in to the home, and another of someone who had been living at the home for some time. We found them to be clear and detailed, giving instructions to staff who provide care and support to both people. Staff spoken to told us they have enough information to deliver care and support to people living at the home. We were told they are given a verbal hand over to ensure they are kept up-to-date with important changes that may have occurred whilst they have been away. Two staff who completed a survey for us as part of the pre inspection process told us “Everyday before starting to work we have a report about all the residents we are always given up to date information about every individual. All the care plans for the service users are all well detailed and easily read.” Both individuals whose files we examined told us that they feel their needs are met by staff, and were very complimentary about the homes manager, deputy and care staff team. They both told us that they have been supported to access healthcare professionals, including doctors, district nurses and opticians. The healthcare records of the two individuals supported these statements. The care plan of the person living at the home for some time had been regularly reviewed. The individual confirmed that they had been part of the reviewing process and felt that they could raise any concerns or issues to the manager or staff any time. The care plan of the most recent person admitted to the home stated it would be reviewed with all parties within 28 days of admission. Two people using the service who completed a survey for us as part of the pre inspection process told us they always receive the care they require. Individuals nutrition and weights are monitored, records of the two individuals we looked at demonstrated that the home closely monitors and acts where required in this area. The requirement made at the last inspection that stated “Care plans must cover all areas of identified need” was considered to be met. The AQAA told us that the home has a medication policy and procedure in place, and that all staff have undertaken training from the pharmacist in safe handling of medication. We looked at the storage of medication and administration records for the two individuals we case tracked. We found these to be satisfactory. We also talked to a senior staff member who confirmed that she had undertaken the medication training. We also saw confirmation of training when we looked at certificates held on individuals training files. The requirement made at the last inspection that stated “A safe system of administering medication must be put in place” was considered to be met. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 14 Observations during the day confirmed that people’s privacy and dignity is maintained. We observed care staff respectfully interacting with individuals. People consulted as part of the inspection process told us that staff are kind and caring. They assured us that their privacy and dignity is maintained at all times. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home told us in the AQAA that the daily living and activities of people using the service are made flexible to suit the individual person. There are a variety of activities that take place, these are displayed around the home to let Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 16 people know the forthcoming programme of entertainment. One person was drawing on a sketch pad when we arrived. Individuals were seen to come and go in all parts of the care home, including the garden. The individuals records we looked at who had been living at the home for some time documented their hobbies and interests. We talked to him about this and he was happy to tell us about his daily routine and interests. He particularly liked growing sunflowers and tomatoes in the homes garden and took pride in showing us his produce. He also told us about visits from his family and his trips out with family members. His care plan reflected what he had told us. The most recent persons records we looked at also documented her personal preferences including her desire to say her bed time prayers and the importance of this to her. She also told us this when we chatted to her. When we spoke to staff about the needs of these two people using the service they were knowledgeable about their likes, dislikes and preferred lifestyles. Residents’ daily records documented what they had taken part in during the day, a wide variety of activities had taken place including dominoes, board games, word searches and crosswords. People using the service were very complimentary about the food. We were told food is cooked at the home, there is plenty of choice and the quality is good. One person we spoke to and whose records we examined told us they enjoyed fish and that their requests were always honoured. One person living at the home who completed and returned to CSCI a pre-inspection questionnaire told us “ there are activities arranged by the home that I can take part in. I like the meals at the home.” The choice of chicken or sausage was given on the day of a visit and people were seen to enjoy the meal in a relaxed atmosphere. Supplement drinks and soft diets were given to those people who had been assessed as requiring it. Refreshments were offered throughout the day. The menu was seen and considered to offer a balanced and nutritious diet. One relative who completed and returned to us a survey as part of our pre inspection process told us “when Mr x moved into Shirwin Court I thought he was nearing the end of his life. But since moving in he has come on really well put on weight loves the home management and staff and gets first class care. I also get treated very well. They keep their residents clean and well dressed and are friendly to all of them. I dont think there is anything more they could do to improve the standard of the home or the care given to the residents. I find everything first class.” Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. People who use the service are able to express their concerns and have access to a robust, and effective complaints procedure, are protected from abuse, and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have received no complaints since the last inspection. One complaint was received by CSCI and referred to the provider to investigate through their own complaints procedure. We examined the central complaints record which detail the nature of the complaint, outcome and action taken. The complaint was not substantiated. It was stated on the AQAA there have been no referrals made to the safeguarding of adults process since the last inspection. There are policies and procedures in place in relation to the topic of protection. All staff complete safeguarding of adults training which is updated at the required frequency. We looked at the records of the two staff on duty on the day of the inspection and found that their training was up-to-date in this topic. We spoke to staff about Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 18 the safeguarding of adults process. Staff were clear about what they should do if they suspect any form of the abuse has taken place. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is adequate. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home was carried out. The environment was found to be clean, tidy and well maintained. Furniture was seen to suit the varying needs of people living at the home. Bedrooms were personalised and individual. The environment of the two people we case tracked were looked at and were Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 20 equipped as their care plans described. The locks on bedrooms can be locked from the inside to maintain the residents privacy and can be opened from the outside in an emergency. These locks do not provide security for residents’ belongings. A number of bedrooms do not have lockable storage space for valuables. This was discussed with the registered manager who said that storage for valuables is available in the office via a safe. People using the service are not encouraged to keep valuables on the premises and any large sums of money are encouraged to be held by their families or representatives. There has been no change to the call bell system since our last inspection. Call alarms are cancelled at the main panel meaning staff do not have to enter the residents’ bedrooms to switch the alarm off. Call switches are labelled in rooms to ensure that residents know what they are and what they are to be used for. The requirement that the registered manager must undertake “A risk assessment of the performance of the resident call alarm must be undertaken to determine its continued suitability in ensuring residents receive help when needed” has been carried out. The risk assessment has taken into account people currently living at the home. The provider/manager has acknowledged the need to keep the risk assessment under review. The risk assessment states “The system will eventually be changed when it breaks down and is not repairable or if we feel it is inadequate and does not meet the needs of the Home/service users or if we encounter any other difficulties relating to the system in place.” Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28 Quality in this outcome area is good. People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was seen to be adequately staffed on the day of the inspection. Rotas seen and discussion with staff and management confirmed that there are usually three staff on duty during the day and one waking night staff. One of the care staff will undertake cooking duties as part of their role. Residents and staff spoken to said they were always enough staff on duty. Staff have been trained to meet the needs of older people. The AQAA stated that 6 out of 8 care staff have NVQ 2 or above qualification. There has been no new staff recruited for sometime, this standard has not been assessed at the Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 22 last two inspections, due to no new recruits being appointed. Induction of new staff could not be assessed at this inspection and will be carried out at the next inspection. Staff are trained in mandatory training topics including moving and handling, first aid, food hygiene, health and safety, infection control and safeguarding of adults. Other training topics include dementia care, continence and care planning and risk assessments. Examination of training certificates, observation of staff practice and discussion with staff at the time of the inspection confirmed they are knowledgeable about the needs of the people they are looking after. They demonstrated they have the required competencies and skills to deliver care and support to people living at Sherwin Court. Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 24 The owners have completed the registered managers award. The registered manager is also a registered nurse. The Manager and deputy are well respected by people living at the home and staff alike. Comments included from one relative “Matt and Naz listen to what you have to say if I need to complain I would tell Matt and Naz (Mr and Mrs Hissaund the owners).” One staff member who completed and returned a pre-inspection questionnaire to CSCI stated “I would speak to our manager whenever you have a problem if you talk to her she will sort it out for you and they are understanding and nice people and so supportive. They always talk to us about our work and give us appraisals.” Quality assurance is evident despite the home being small in size. The homeowners have an open door policy where people using the service and their families can approach them with any issues they wish to discuss. Mr and Mrs Hissaund attempt to gather more formal views to inform whether the home meets its stated objectives on an annual basis. This is met with some reluctance because people feel that the owners work in the home regularly where they have access to discuss any issues they wish at any time. A visitors comment book is available and one comment seen since the last inspection stated “my relative has improved greatly the management are lovely. People very homely they take great care with all their residents and visitors.” The home also monitors quality of its staff by undertaking regular supervision of staff both formally and informally through observation of their practice. We saw evidence of this in staff personnel files and through discussion with staff during the inspection. There are policies and procedures in place for the handling of individuals money and the safekeeping of valuables. The system was monitored and had been followed in accordance with good practice. Records relating to individuals finances were satisfactory at the time of the inspection. It was stated on the AQAA that that all routine required maintenance checks had been carried out as required by regulation. Accident records were examined and were satisfactory, where required incidents had been reported to the reporting of injuries, diseases and dangerous occurrences regulations authority. The requirement made at the last inspection that stated “All staff must have the benefit of fire drill at suitable intervals” was considered met. Records seen and confirmation by staff indicated that this had been carried out. Shirwin Court DS0000017022.V369012.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Shirwin Court DS0000017022.V369012.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP22 Good Practice Recommendations It is recommended that the call system be replaced with one that has to be cancelled within the residents’ bedrooms. Bedroom door locks must allow the resident to lock the door when they are not in the room to keep their valuables safe. 2. OP24 Shirwin Court DS0000017022.V369012.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 Shirwin Court DS0000017022.V369012.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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