Inspection on 16/01/07 for 1 Curlew Close

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Curlew Close 22/12/05

1 Curlew Close 28/06/05

1 Curlew Close 30/03/05

1 Curlew Close 18/10/04

1 Curlew Close 18/10/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 1 & 2 Hunts Lane Wellington Hill Horfield Bristol BS7 8UW Lead Inspector Ashley Fawthrop Key Unannounced Inspection 16 and 19th January 2007 09:30 th 1 & 2 Hunts Lane DS0000020340.V314994.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 1 & 2 Hunts Lane DS0000020340.V314994.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. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 & 2 Hunts Lane Address Wellington Hill Horfield Bristol BS7 8UW 0117 9354310 0117 9699000 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) www.brandontrust.org The Brandon Trust Mrs Dolores May Smart Care Home 9 Category(ies) of Learning disability (9) registration, with number of places 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Staffing Notice dated 17/03/1999 applies Manager must be a RN on parts 5 or 14 of the NMC register May accommodate up to 9 persons, aged 35 years and over, requiring personal care. May accommodate 1 named person aged 65 years and over. Date of last inspection 13th December 2005 Brief Description of the Service: Hunts Lane is arranged in two separate bungalows capable of accommodating nine adults with a learning and physical disability. A small tarmac area separates the two homes. The homes have aids and adaptations to assist in the provision of personal and nursing care. The home is owned by Western Challenge and leased to the Brandon Trust who is responsible for the management of the care delivery. Set off the road and surrounded by garden, the home is close to local amenities and on the main bus routes into the city centre. It is within walking distance of pubs, churches, shops and open parkland. On the 19 January 2007 the charge for services were levied at £1,218.92. Additional charges are levied for extra social activities, hairdressing, music sessions and mini bus hire. These charges vary. Aromatherapy is £8.00 per session. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course two days. This was due to the home moving back into it’s renovated premises and it was reasonable to split the inspection over two days so that the process would not be too intrusive as the people using the service and the staff were settling in. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, the action plan submitted following the previous inspection, and reports from other agencies, i.e., the Fire Officer. This information was used to plan the inspection visit. The inspector case tracked four people using the service. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Pre inspection information was received before the visit was done and on the day of the inspection the staff were open and helpful throughout. The inspection included looking at records such as care plans and reviews of the care for people using the service and other related documents. The inspector also read policies and procedures relating to the protection of vulnerable adults and health and safety. The views of the staff and people using the service were gathered either by face- to- face discussions or by surveys. What the service does well: The service provided care in two bungalows that have been recently renovated to provide a good environment with specialist equipment to meet the needs of the people using the service. People are given good information prior to admission so they can make a judgement on whether the service can meet their needs or not. People said that the overall standard of care is excellent, but some felt there needed to be more staff on duty. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 6 Others said that the care was always beyond the call of duty and that staff always us make them feel welcome into the home as though they were part of a family. Care and activities are both seen as important and people who use the service are given opportunities to have friends and relationships. The staff are given the opportunity to train and develop this allows them to provide a good level of care as they have the skills needed. What has improved since the last inspection? What they could do better: The staff must ensure that were a risk has been identified then there has to be some ways of reducing the risk written into the care plan so that staff can judge whether the care being given is appropriate or not. Parts of one person’s care plan was missing making it difficult to assess all of his needs; where records are being transferred to a new system staff should make sure all the information has been transferred. Prescribed substances such as medicated bandages, Thick and Easy, sprays and food supplements were not being signed for. Staff must sign for all prescribed substances as evidence that the product has been given or treatment carried out. The book where complaints are recorded could not be found at the time of the inspection. This may be due to the home recently moving back into the home; however, records must be kept safe at all times. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 7 Privacy for people using the service had not been properly considered before moving back into the home. There were makeshift curtains in the dining as the permanent one had not been fitted. The two en-suite toilets must have the water pipes boxed in as they present a risk of injury should someone fall against them. 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. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. People wishing to use the service do have the necessary information made available to them to ensure they are supported to make an informed choice about the home and the services offered. Pre placement assessments are seen as important and provide good information, but more use should be made of the introductory visits. The staff do have the collective skill to meet the needs of the individual but external advocates should be encouraged. EVIDENCE: Since the last inspection the statement of purpose been updated and now contains details of the CSCI. The service user guide was also available and continues to be user friendly. The statement of purpose and the service users guide describes the type of service care and services offered by the home. This information is available to all people that use the service and contains enough information to enable potential service users to make an informed choice of where to live. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 10 Pre placement assessments are done prior to moving into the home, members of the homes staff are involved and the assessment gives good information on the needs of the individual before their admission. I was informed that people wishing to use the service have the opportunity to visit, but this is not always recorded and an opportunity to record an assessment in the home prior to admission is lost. Staff receive training that is based on caring for people with learning difficulties. This makes sure that the staff have the knowledge to meet individual needs. There are also other health care professional involved and where specialist care has been identified people who use the service have access to wide range of National Health Services. Staff described ways they communicate with people using the service in ways that are best for them these included sign language or the use of pictures so that individuals can express their feelings. I was informed that the staff advocates people who use the service and have no relatives or representatives. I recommended that the home look at ways the home could encourage external advocates. This would give people using the service the opportunity to meet with independent people make the service more open to others. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The care plan does reflect the needs of the individual and takes into consideration their views. Recording in the care plan is not always enough to judge whether his needs are being met or not. EVIDENCE: The care plans and other records of four people who use the service were case tracked. Most contained good information including the persons daily living skills this allows staff to assess the needs and see any changes that take place. The care plan does reflect the needs that were identified at the pre placement assessment and are in picture format that can be understood by many of the people using the service. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 12 There were some gaps in the recording where a risk had been identified and evidence that an individuals wellbeing was being affected but no intervention action had been recorded. Documentation had at time been made in pencil this is poor practice as the record can be altered or removed without being noticed. On another care plan there were parts of the document missing so that it was difficult go make up a full picture of the persons needs. The care plan is written in the first person and asks people who use the service questions about themselves and this encourages the person using the service to be involved in the care. Staff were able to describe some of the actions they took to ensure residents’ choice was assessed, respected and acted upon. The staff gave examples of how residents with limited verbal communication were offered choice. That staff continue to have a good understanding of residents communication needs and were able to understand and respond to those needs, even those who have very limited communication. The staff said this is interpreted through expressions and body language. Risk assessments were well written and contained the necessary information make sure that the people using the service are supported to take risks as part of an independent lifestyle. Risk assessments were in place regarding mobility and posture and the appropriate healthcare assessments were also carried out. I recommend that information and action to be taken by the staff regarding risk assessments should be written in the main care. This makes sure that all the information is in one place and easy for staff to get to. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Individual lives styles are seen as important and people using the service are given the opportunity express their individuality. Families are involved with the care and are kept informed and the meals are appropriate. EVIDENCE: People who use the service have the opportunity to be involved in activities both in the home either by participating or observation or in the community where several people continue to visit day centres Activities and socialising is part of the care planning and shows that the social needs of the individual are as important as physical needs. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 14 People who use the service said that social activities depended on staffing levels or who was on duty. I was informed that activities are to be developed and making them more structured and aimed at the individual as well as the group. Service users were seen to be involved in activities or watching their own televisions or listening to music. Staff assist individual to go shopping for personal items there was evidence that people could express their individuality in the way they dressed and personal appearance. Significant people in the lives of people who use the service are recorded in the care plan including friendships that have developed between them. There is evidence that families are involved in the care of their relatives and are invited to attend meeting and reviews to keep them updated with the needs of their relatives. People using the service said that they were treated well by staff and that many knew who to go to if they were unhappy. Staff normally do the food shopping as this was felt to be more of a task than a social activity but staff did say that there were a small number of people who could assist and this is to be included in the development of activities. I was informed that there are no set meal times and that meals are prepared when people are hungry. Staff prepare the meal and everyone eats together. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. Support for people using the service is given in a personal relaxed and unobtrusive way. The home cannot evidence that all the medications are administered to service users, as there are gaps in the recording. EVIDENCE: Staff were able to describe how they personally support people. Bedtime routines are very individual and they were able to assess who was tired and when to suggest bedtime. A number of service users go to day centres and have to be up early in the morning, on these days they are encouraged to go to bed at a reasonable time to allow them to have enough sleep. People were supported in a relaxed way meal times were not rushed. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 16 There was evidence in the care plans that people are given access to either specialist care relating to their personal disabilities or a range of health care services such as opticians, dentists and chiropodists. There is a medication policy that has been developed by The Brandon Trust and is available to all staff. There are also UKCC guidelines available on the covert administration of medications. The medication administration system is pre packed, this reduces the risk of error on giving them to people because the chemist has already packed them. All the Medication Administration Sheets are pre printed this reduces the risk of inaccurate recording. There were a number of gaps in the recording of medications these related to the administration of food supplements, sprays and prescribed bandages for dressings. This is poor practice where a substance has been prescribed whether it be a tablet food supplement or a dressing to aid the healing process. There must be a signature to evidence that the treatment has been carried out. 1 & 2 Hunts Lane DS0000020340.V314994.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to the home. The procedures relating to complaints are robust but due to the complaints record not being available for inspection there was no evidence that service users are protected. People who use then service are protected abuse and neglect. EVIDENCE: There have been no complaints received by the Commission (CSCI) since the last inspection. All the people using the service have an easy to read with pictures complaints procedure in their care plan. Staff said that complaints are looked at on an individual basis and are logged in the complaints book unfortunately due to the home moving premises recently this could not be found at the time of the inspection. I was informed that no formal complaints had been received but where people had been not happy with the food or lack of activities these had been logged. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 18 People using the service said that if they were unhappy or had a complaint they knew who to go to also that staff usually listens to them and act on what they say. The DOH ‘No Secrets’ in Bristol document was readily available and displayed in the office; this links closely with the Brandon Trust Protection of Vulnerable Adults Policy. Records show that staff carrying out their Learning And Disability Award Framework (LADAF) has to complete a comprehensive unit on protection and abuse. 1 & 2 Hunts Lane DS0000020340.V314994.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The environment is well designed for the needs of the service users EVIDENCE: The home has recently been renovated and redecorated. All rooms are now single two have en-suite hand basin and toilet. On inspecting these it was noted that the pipe work opposite the toilet could be injure someone if they fall against it. The pipe work must be boxed in. Bedrooms are individually decorated and furnished with the people’s own furniture and personal possessions making sure that the rooms are individual and have a feeling of ownership. Bedrooms are also large enough to accommodate any specialised equipment required. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 20 The toilets showers and baths are appropriate with suitable equipment. There are two fully equipped kitchen unfortunately one cupboard in each has been restricted due to the positioning of the water boiler. The entrance and exit from the lower bungalow is by a wheelchair lift only there is no other level exit and staff were concerned that people would be stranded if the lift did not work. The garden needs to be completed because at the time of the inspection there was soil or building rubble. The soil in the back garden was very wet and was pooling by the wall and may cause damp in the future. There were Make shift curtains on the dining room windows as the made to measure curtains were not due to be fitted for a other three or four weeks. This is not good practice, as the privacy of people using the service was not being protected. The home was clean and free from offensive odours at the time of the inspection. 1 & 2 Hunts Lane DS0000020340.V314994.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The staff have the skills and competencies to meet the needs of the people that use the service. The recruited and selection procedures appear to be robust and staff continue to be offered training opportunities. EVIDENCE: All the staff have job descriptions these give staff clear instruction as to what their roles and responsibilities are within the team. There was evidence in both the care plans and observations by myself during the inspection that the staff and people using the service had developed good relations. This allows staff to support individuals better and is good practice. The staff are enabled by Brandon Trusts training programme to competent and knowledgeable about the service they provide. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 22 Training includes mandatory training such as Manual Handling, Food Hygiene, Health and Safety and First Aid. Training aimed at meeting the needs of people using the service includes Understanding Mental Health and Learning Difficulties, Basic Sign Language (Makaton) Understanding Autism and Inside I’m Dancing (none verbal communications.) Staff also undertake National Vocational Qualifications training. And training in the Protection of Vulnerable Adults, this training gives the staff the skills to protect people using the service from abuse. All new staff undertake the LADAF induction package. The registered nurses training records demonstrated they were attending courses, which provided the skills needed to meet the people’s needs. There was evidence to show that staff receive regular supervision sessions and various policies and procedures are discussed. Supervision sessions are also used to ensure staff are aware of their roles and responsibilities in the home and identify training needs. Policies seen evidence that the Brandon Trust operate a robust recruitment procedure however many of the records relating to interview and selection, references and Criminal Record Bureau checks are held at HQ. Information held within the home includes a summary of staff details that details personal details, relevant qualifications, personal identity numbers for qualified nurses, proof of identification and the date of the Criminal Records Check and the reference number. However, and agreement has been made between the Commission (CSCI) and the Brandon Trust that all the recruitment information can be held centrally by their Human Resources department. 1 & 2 Hunts Lane DS0000020340.V314994.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The conduct and the management of the home is good. The staff and people who use the service are protected the Health and Safety policies and procedures. EVIDENCE: The manager keeps herself updated by attending various training courses. She is an NVQ assessor and has completed the Internal Verifiers (IV) course. As well as a nursing qualification in learning disabilities the manager also has a qualification in management (RMA). She supports the Brandon Trust by providing various training sessions to teams regarding ‘report writing skills’ and ‘pressure area care’. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 24 The policies and procedures in place are accessible to staff. New policies are put in the communication book for staff to read and are discussed at supervision sessions. The in-house policies reflect the needs of the people using the service and include the use of monitors in bedrooms, restraint and the use of bedrails and chair belts. On speaking to staff they were ware of Brandon Trusts policy on restraint, but there were no people in the home that needed to be restrained due to inappropriate behaviour. The home uses the Organisation’s quality monitoring system and could demonstrate that monitoring was in progress. The home carries out regular Health and Safety checks and audits. There is a folder available containing data information sheets on hazardous substances used around the home. The fire prevention information was up to date. The last fire lecture was held on the 31 May 2006. Tests to the fire system are done weekly and there is evidence of regular fire drills. Accidents and incidents are recorded well and the Commission (CSCI) is informed in writing. The certificate of liability insurance was displayed alongside the registration certificate. The manager said the homes business plan is in line with the organisational strategy plan. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 1 & 2 Hunts Lane DS0000020340.V314994.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. 1 Standard YA6 Regulation 15(1) Requirement The registered provider must make sure that the care plans are complete for all people using the service. Where risks are identified there must be written instructions to staff about how this is to be managed. The registered provider must make sure that all substances prescribed for people who use the service must be signed for on administration. The registered provider must make sure that the complaints record is kept in a safe place and the record made available for inspection on request. The registered provider must make sure the privacy of people using the service must be maintained at all times. The registered person must make sure that the environment is free risk Timescale for action 30/04/07 2 YA6 15(1) 30/04/07 3 YA20 13(2) 31/03/07 4 YA22 22(3) 31/03/07 5 YA24 12(4)(a) 28/02/07 6 YA24 13(4)(a) 28/02/07 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 27 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 Where a risk has been identified the action to be taken by staff to reduce this should be transferred to the main plan so that all the information is in one place. 1 & 2 Hunts Lane DS0000020340.V314994.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 1 & 2 Hunts Lane DS0000020340.V314994.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!