Care Home: Woodridge Road

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What the care home does well People`s needs are assessed before they move into the home so they can be confident their needs will be met there. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them.People who live in the home are offered support with personal care in a way that they like and that meets their individual needs. Staff have good relationships with people who live in the home and people say, they "are very good and nice, they help me". Regular health and safety checks are made so that equipment is well looked after and safe for people to use. What has improved since the last inspection? Plans that explain how to care for people and help them stay safe are better written so that people`s needs are understood and met. There are more staff on duty during the day so that people have opportunities to go out and do things they enjoy. There are good procedures to listen to people and keep them safe from possible harm. Cleaning routines are better so that people live in a more hygienic home. What the care home could do better: The standards in the kitchen could put people at risk, as the work surfaces and units are broken and stained and difficult to keep clean. There is no private space for meetings or for staff to share information with each other. This does not respect the privacy of people who live in the home. Some health and medication records were not well written which means that people`s needs might not always be fully met. The number of staff on duty at night needs to be looked at so that people can be confident their needs will be met. Staff need some extra training to help them meet the needs of people who live in the home. CARE HOME ADULTS 18-65 Woodridge Road 6a Woodridge Road Aston Birmingham West Midlands B6 6LN Lead Inspector Julie Preston Unannounced Inspection 7 February 2008 09:30 th Woodridge Road DS0000016946.V350964.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 Woodridge Road DS0000016946.V350964.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. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodridge Road Address 6a Woodridge Road Aston Birmingham West Midlands B6 6LN 0121 240 4480 F/P 0121 240 4480 maggieoakley@southbirminghampct.nhs.uk www.midlandheart.org.uk Focus Futures Ltd South Birmingham Primary Care Trust Mrs Margaret Judith Oakley Care Home 4 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) Category(ies) of Learning disability (4) registration, with number of places Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years. A maximum of 4 service users may be accommodated for reasons of learning disability Two named service users over the age of 65 years can be accommodated providing the home can demonstrate it can meet their needs and this is subject to periodic review. 9th January 2007 Date of last inspection Brief Description of the Service: 6A Woodridge is a modern bungalow, situated in a quiet cul-de-sac in Aston. The home is registered for four adults with a learning disability. At the time of inspection the residents were all female. The home is close to main roads that are served by public transport, enabling travel into the city centre, and the One Stop Shopping centre. The home is purpose built. There are four single bedrooms, a communal assisted bathroom, shower room, laundry, kitchen, dining room and lounge. Access to the laundry and kitchen is poor for people who use a wheelchair and limit their opportunity to develop independent living skills. There is no office and this has an impact on privacy and dignity, as there is no private place for meetings or phone calls to take place. There is off road parking for approximately three cars. The home has a tidy garden at the rear, which has facilities for service users to sit, out, and undertake gardening. The home has a very stable staff team, with few vacancies. The home has a registered manager. The current fee level is £1582.07 per week. Additional charges are made for toiletries and activities. The CSCI inspection report was available in the home for people to read. Woodridge Road DS0000016946.V350964.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. Two service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 6 People who live in the home are offered support with personal care in a way that they like and that meets their individual needs. Staff have good relationships with people who live in the home and people say, they “are very good and nice, they help me”. Regular health and safety checks are made so that equipment is well looked after and safe for people to use. 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. Woodridge Road DS0000016946.V350964.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 Woodridge Road DS0000016946.V350964.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): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: There is a statement of purpose and service user guide, which give information about the services and facilities within the home. The service user guide is presented by use of plain language and pictures to make the content more accessible to people who may have difficulty reading. One person commented that they had received information about the home and visited on several occasions before deciding to move in. There is a procedure for assessing the needs of people who may wish to live in the home prior to them being offered a place so that they can be confident that their individual needs can be met there. A copy of the assessment made Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 9 for the placement of the person most recently admitted to the home was seen on file, which showed that the admission procedure had been followed. Woodridge Road DS0000016946.V350964.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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems of care planning and risk assessment in place to enable peoples’ needs to be understood and met. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: Care plans were sampled for two people who live at Woodridge Road. Both had been reviewed in January 2008 to make sure that the information was relevant to people’s current needs. The sampled plans gave detailed information about how staff should support people in order to meet their individual needs in relation to health, personal care, communication, culture and social and leisure preferences. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 11 Monthly review records sampled showed that care plans had been regularly reviewed to make sure they contained information that was relevant to people’s current needs, so that consistent care could be provided. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. Risk assessments sampled had been reviewed on a regular basis and staff were able to describe the measures in place to reduce known risks to individual’s health and well being. People who live at the home need assistance to manage their money. There are systems in place to record individuals’ income and expenditure, which are audited for their ongoing protection. As raised at the last inspection, there is no private space to undertake meetings, reviews or private discussions, which is necessary to promote confidentiality within the home. All these activities take place in communal areas or in people’s bedrooms. It is recommended that the arrangements be reviewed so that individual’s privacy is more effectively respected and upheld. Woodridge Road DS0000016946.V350964.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. This judgement has been made using available evidence including a visit to this service. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: People’s activity preferences had been recorded in their plans of care. Daily records were sampled to check that people had regular opportunities to take part in things they enjoy doing. Records showed that people undertake many activities such as going shopping, to church, music sessions, trips to local places of interest, the cinema and out for meals and drinks. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 13 There was comprehensive information in sampled care plans about how staff should support people to pursue their leisure interests. For example one care plan referred to the type of music and specific radio station preferred by the person. Staff made sure that this choice was respected during this visit. Detailed information about people’s spiritual needs had been recorded and it was evident from talking to staff and looking at daily records that individual’s needs were being met in this area. During this visit some people took part in a sing-song with staff, which from observation of their responses they clearly enjoyed. One person stated in response to a questionnaire sent by the Commission, that they always chose their activities and enjoyed those that they took part in. Care plans and daily records sampled showed that individual’s independence is being promoted by the staff team so that people have opportunities to maintain and develop their skills such as choosing their own clothing, helping with meals and drinks and tidying their bedrooms. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about peoples’ relatives birthdays, so that cards and presents could be sent. The home has a visitor’s policy and the manager commented that relatives have regular contact either by telephone, email or in person. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts and low fat meals, which is reflective of people’s cultural and healthcare needs. Specialist cutlery, plates and bowls were provided for some people to enable them to maintain their independence at mealtimes. The menus sampled were reflective of individuals recorded food preferences. Woodridge Road DS0000016946.V350964.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 adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are offered support with personal care that meets their individual needs and preferences. A lack of staff training and detail in health and medication records may lead to individuals needs not being fully met. EVIDENCE: Two personal and health care plans were sampled at this visit. There was some good information about individuals’ personal care needs and preferences, which staff clearly understood so that people receive care in a manner they need and like. Records showed that individual routines had been planned for so that support could be provided according to their preferences. For example, one plan described how a person liked a cup of tea in bed each morning and their preferred brand of make up and nail varnish. The person concerned said that the staff team always respected her choices. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 15 Financial and daily records sampled showed that people shop for their own toiletries and clothes and use local hairdressers, with the support of staff as part of their regular personal care routines. Records showed that people have regular appointments with healthcare professionals and the outcome of this contact had been documented so that staff had accurate information about individuals’ state of health. Healthy Living Plans were seen to be implemented, these are personal plans that describe what a person needs to stay healthy and the healthcare services they need to access to do so. The plans sampled showed that individual’s had been referred to specialist healthcare professionals such as nutritionists and physiotherapists so that people have access to advice and support in accordance with their needs. There were systems in place to monitor individual’s health such as weight and continence records, which had been completed on a regular basis and reviewed each month by the staff team. Staff commented that the monitoring records enabled them to identify potential health problems and make referrals to appropriate professionals without delay. Some people living in the home have difficulty moving around. Moving and handling risk assessments had been completed to identify how to reduce known hazards and the risk of potential harm to the person. The content of some risk assessments was vague stating, “full support” but with no further information about what that meant or whether aids and adaptations should be used. Staff were able to describe how they support people, which the registered manager confirmed was consistent with good practice, however individual risk assessments must be reviewed so that all staff have clear information upon which to provide care to people who live in the home. One person living in the home has needs, which the staff team have not received training to meet. The person’s placement is being reviewed by Birmingham Social Care and Health (who arranged the person’s placement), however in the meantime; specific training in Acquired Brain Injury must be provided so that the staff team have a better understanding of how to meet the person’s needs. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medicines were securely stored in a locked cabinet in a small storage area leading off the dining room. Each medication record contained a photograph of the person and a description of how they like to take their medication so that it is clear to staff whom to give the medication to and how to give it. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 16 Where people are prescribed medication on an “as required” basis, written protocols were in place to guide staff as to when they should be given. Two errors in the medication records sampled were observed. In one case the medication record indicated that six doses of medicine had been given to a person but the amount of medicine remaining showed that seven doses had been given and that the record had not been signed for the seventh dose. In another case, medication had not been given as prescribed and an “X” had been entered onto the medication record. There was no explanation of what this meant or why the medication had not been given to the person. These issues need to be addressed so that people receive their medication safely and maintain good health. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: There have been no complaints made about the home since the last inspection. A log of complaints is maintained that records the nature of the complaint and the action taken in response. There is a complaints procedure, which was presented using pictures and symbols so that it is easier for people who have difficulty reading to understand. A summary of the procedure was on display in the hallway so it was available to visitors to the home. One person confirmed that they knew they had the right to make complaints and knew who to speak to if they needed to do so. At the previous visit (January 2007) it was reported that the behaviour of some people who live in the home had impacted on the lifestyle of others who live there. The sampling of incident records and Regulation 37 notifications (reports that describe an event that has had an adverse effect on people in the home and sent to the Commission) showed that the number of incidents had vastly reduced. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 18 There was information in individual records to instruct staff how to use techniques to minimise behaviour that is challenging for the ongoing protection of people who live in the home. Staff development records showed that all had received training in safeguarding vulnerable adults so that allegation or suspicion of abuse could be responded to in accordance with the home’s policies and procedures. Staff spoken to during this visit were aware of the procedures to follow to protect the people who live in the home. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Outstanding redecoration and refurbishment impacts upon the comfort and safety of people who live in the home. EVIDENCE: Woodridge Road is a bungalow situated in a cul de sac in the Aston area of Birmingham. There are shopping and leisure facilities nearby, which is important to people who live at the home as they enjoy using them. Bus routes are within walking distance, which again is important as some people use bus passes to travel to the city centre and other local resources. Shared space consists of a kitchen/dining room, which is separated by units and leads onto the garden. There is a lounge and a small laundry room as well as bathrooms and toilets. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 20 Some aids are provided to enable people with a physical disability to have greater independence such as handrails and adapted bath and shower facilities. Each person has their own bedroom. The two seen during this visit were clean and warm and reflected the person’s individual tastes. One bedroom had damaged wallpaper, which did not look attractive. A member of staff commented that the room had not been redecorated for a number of years. The kitchen had not been repaired since the last visit when it was reported “It is very worn the surface of the doors and inside cupboards have started to break down, and cannot be cleaned to the required standard presenting the potential for an infection control risk.” At this visit a representative from the registered provider who own the building, was present who commented that the premises would be redecorated according to the preferences of the people who live there. There was no confirmation that the kitchen would be repaired or refurbished. Improvements had been made to cleaning routines so that mops and cleaning materials were stored in a way that did not pose an infection control risk to anyone in the home. This report has identified concerns about the lack of space for personal meetings and private discussion, which currently take place in the dining room. The computer used by the staff team is also located in this room and staff have no space to complete records or handover information other than in the shared areas of the home, which has an impact on the privacy of people who live there. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty is not always sufficient to ensure that people’s needs are consistently met. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: The staff rota sampled for a three-week period showed that three staff are on duty from 7.15am until 9.45pm with one member of staff awake at night. It was reported that one person living in the home has begun to get up very early in the morning, which means that others may have to wait for support until the second staff member arrives at 7.15am, as all need one to one assistance to get up in the morning. There was no evidence that staffing levels at night had been reviewed to make sure that each person’s needs could be met. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 22 Most people who live in the home were not able to comment on the qualities of the staff team as they have complex communication needs. From observation of staff interaction with people however, it was evident that good relationships had been formed. People sought out staff throughout the visit and their body language and facial expression indicated that they were happy and comfortable with the approach of the staff on duty. One person said that the staff “are very good and nice, they help me”. From discussion with staff it was evident that they have good understanding of peoples’ needs. Staff talked with confidence about the agreed strategies in place to support people to maintain their independence and manage their behaviour, which was consistent with information in individuals’ plans of care. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. To ensure that people are supported by a qualified staff team at least 50 of staff should achieve an NVQ in care. Information received in the Annual Quality Assurance Assessment stated that fourteen of the fifteen current staff members have either achieved or are working towards this qualification. The home has a rolling programme of training so that staff have access to regular sessions and updates to assist them to care for the people who live there. This report has identified that training in Acquired Brain Injury is needed and the staff training schedule showed that the majority require updated sessions in minimising confrontation. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and peoples’ health and safety is promoted and protected. EVIDENCE: The home has a registered manager, who has achieved her NVQ Level IV in care and is due to complete her registered manager’s award. It was evident, from discussion with the manager that she has kept up to date in developments in the social care field, for example completing a degree in health and social care. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 24 The registered manager was present throughout this visit and demonstrated commitment to creating positive outcomes for the people who live at Woodridge Road. Representatives from Focus Futures and South Birmingham Primary Care Trust visit the home on a regular basis to comment on the standard of care provided. There was written evidence that the registered manager had taken action to address some of the issues raised as a result of these visits for the benefit of the people who live in the home. The Primary Care Trust has a quality assurance policy which includes monthly monitoring of the success of the home in achieving its stated aims and objectives and a number of audits to promote better outcomes for people who live in the home, such as care plan reviews and financial audits. From observation of care plans and financial records it was evident that the audits had taken place. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. Each person has a fire safety plan that describes how to assist them to evacuate the home safely in the event of an emergency. The staff development records looked at showed that all had received training in fire safety, food handling and first aid to assist them to maintain the health and safety of people living at Woodridge Road. Gas and electrical equipment had been regularly serviced to make sure it was safe to use and did not pose unnecessary risks to people who live in the home. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 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 2 25 X 26 2 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 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 2 2 X 3 X 3 X X 3 X Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 13(5) Requirement Timescale for action 01/04/08 2 YA20 13(2) 3 YA24 23(2)(b) 13(3) Risk assessments must be completed that clearly describe how to reduce hazards and maintain the safety of people who require moving and handling. 01/04/08 People must receive their medication as prescribed and codes entered onto medication records must be explained in writing so that the record clearly demonstrates whether the person has received their medication, or that other action has been taken in response to circumstances where medication has not been given. Kitchen doors, drawer fronts, 01/06/08 and shelves inside cupboards must be maintained in a good state of repair so that people live in a safe and hygienic environment. Not met from last inspection on 9/1/07. 4 YA26 23(2)(b, d) Bedrooms must be DS0000016946.V350964.R01.S.doc 01/05/08 Version 5.2 Page 27 Woodridge Road redecorated so that people live in a comfortable environment. Not met from last inspection on 9/1/07. 5 YA33 18(1)(a) The number of staff provided at night must be reviewed, and action taken to ensure this safely meets people’s assessed needs. Not met from last inspection on 9/1/07. 6 YA35 YA19 18 (1) c (i) Staff must receive training in 01/05/08 Acquired Brain Injury and managing confrontation to enable them to meet people’s needs more effectively. Not met from last inspection on 9/1/07. 01/04/08 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 YA10 Good Practice Recommendations Consideration should be given to providing sufficient space to enable private discussion and meetings to take place so that the privacy of people who live in the home is not compromised. Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Woodridge Road DS0000016946.V350964.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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