Inspection on 12/06/07 for 1101 Bristol Road

This inspection was carried out on 12th June 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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

CARE HOME ADULTS 18-65 1101 Bristol Road 1101 Bristol Road Birmingham B29 6LX Lead Inspector Susan Scully Key Unannounced Inspection 12th June 2007 10:00 1101 Bristol Road DS0000068462.V342074.R02.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 1101 Bristol Road DS0000068462.V342074.R02.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. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1101 Bristol Road Address 1101 Bristol Road Birmingham B29 6LX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 478 1847 0121 477 5463 nicola.archer@birt.co.uk The Brain Injury Rehabilitation Trust Nicola Archer Care Home 8 Category(ies) of Physical disability (8) registration, with number of places 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: new service condition to be reviewed. Date of last inspection New service Brief Description of the Service: Bristol Road is a purpose built home, which provides residential accommodation on both the ground and first floors. The home provides both long term and short-term placements to people who have sustained a brain injury. The purpose of the service is to support and assist the people who live in the home in their every day living tasks, to assist rehabilitation back into the community and to promote their independence as much as possible On the ground floor is a laundry, dining area and a communal lounge where people can sit and socialise. Meals are prepared in the main kitchen that is open at all times. To the front of the building there is ample parking for vehicles. To the rear of the building there is a paved/grassed quadrangle where people can sit out during good weather. On the first floor there is an independent flat where one person is currently accommodated and comprises of a kitchen and a lounge area. The flat enables the person to live independently with support if needed and is part of that person rehabilitation back into the community. There is a good supply of assisted bathing facilities and toilets strategically located throughout the home. The communal areas and bedrooms are pleasantly decorated are personal to the individual and has good natural lighting. The fees payable vary according to the individual needs of the person using the service. There is a financial assessment completed by the relevant authority to determine if a top up payment is required in addition to funding from the local authority the lowest fee being £1500 per week. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 5 Information is made available to the people who use the service in the form of a Statement of Purpose and Service Users Guide from the organisation this give information about the service and its aims and objectives. In additional interested parties may obtained information of how the service is meeting the National Minimum Standards from the intranet at www.csci.org.uk were you can obtain the latest inspection report 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of one day by two inspectors this was an unannounced visit. This was the first inspection since the home was registered with the Commission For Social Care Inspection (CSCI) in November 2006. The service manager assisted the inspectors throughout the inspection. Prior to the inspection the Commission sent an (AQAA) Annual Quality Assurance Assessment for the provider to complete. This allows the provider to give information to the Commission about the service provided and what they do well and what they could do better. This information has been condensed with in the report All relevant documentation was examined during the inspection and included five care plans, one of which was case tracked in order to ensure that all identified needs were being met. Case tracking is a method used by inspectors where all information pertaining to that person care is looked at. Five staff personnel files, staff training and formal supervisory meetings were checked. A tour of all communal rooms and a number of people’s bedrooms was carried out. As part of the inspection, surveys were sent out to six service users and five staff. Other surveys were given to carers, and relatives. Seven surveys were returned. All service users have cognitive impairment and do not retain information. Because of the complex needs of the individuals either relatives or staff have completed the surveys on the person’s behalf. Four surveys that were returned reflected that they were satisfied with the service. One relative comments were “It is a little early to comment on the care at the moment as the home has not been open very long, however my relative seems to have settle well, it would be better to comment in 3-4 months time’’. Professionals working with the service users were also contacted for their opinion of the service, any comments received have been included in this report. What the service does well: There is excellent information on activities that each person attends both in the home and in the community so that people have the opportunity to live varied and meaningful lifestyles. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 7 Regular meetings are held with staff and relatives. There is ongoing communication with the people who use the service. This enables good communication between those that are involved in the person’s life, and maintains good links with people who are important to the person living in the home. The people who use the service are invited to participate in the recruitment this enable them to have a choice of who they want to work in the home process and is within their scope of ability. Each person is allocated a support worker who is responsible for ensuring the service user is kept informed on all issues relating to him or her. The management ensures only experienced and skilled staff are employed and ensures all the necessary check are completed before staff commence employment, this means people are safe. The home takes an active approach to equality and diversity and has identified a number of changes they have needed to make to ensure this is promoted within the service delivery. The home is constantly looking at ways to improve the service and has developed an improvement plan for the next 12 months. What has improved since the last inspection? What they could do better: Care plans could be improved further to ensure choices and preferences are included. Given the complex needs of the people who use the service this will ensure the choices are made by the person, implemented, monitored and reviewed. Political rights and choices could be improved to ensure the people who use the service are given the opportunity to vote. This also applies to the choice of general practitioner. Records must show how the person has chosen their particular doctor. Observation records completed by staff need to evidence how each identified task is completed. This will ensure the person choice of how care is provided is adhered to. Medication records need to improve to evidence all medication coming into the home. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 8 Any surplus medication needs to be recorded as carried forward on the next medication administration record (MAR charts). This will ensure there is not a build up of stock and an adequate audit can be completed. 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. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 9 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 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of the people who use the service are fully assessed before they come to live in the home. This ensures all parties can be confident that the needs of the person can be met. EVIDENCE: Each person is given a comprehensive statement of purpose and service user guide that sets out the aims and objective and philosophy of the home. Due to the complex needs of the people who use the service, other healthcare professional and relatives are involved in the decision-making and the trial visit to the home is available. Each person has cognitive impairment and cannot retain information so it is very important that a Multi disciplinary team is involved in the pre assessments to ensure the placement is suitable and would be in the best interest of each individual. When a decision has been made to move into the home the admission process involves an allocated support worker to help the person settles in. The allocated support worker will work with the individual to prepare a care plan 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 11 with information received from relatives, previous history, and health action plans to ensure the persons needs are met in a way that meets their needs and preferences. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual plans include good quality information about how support should be given. More attention to detail would mean that each person would receive their care in a way they prefer. Risk assessments ensure information is recorded to fully protect the people who use the service from harm. EVIDENCE: Care plans identify what the person is able to do independently and states what assistance is required from staff in order for the person to maintain their independence as much as possible and to ensure all their needs are met. Each care plan sampled is very detailed about the person life history, expectations, and rehabilitation and included health action plans. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 13 All care plans are reviewed regularly with the involvement of the service users, support worker, and other health care professionals, such as psychologist, occupational therapist and consultants, to ensure any changes that effect the care provided is incorporated into the care plan and can be closely monitored. This will ensure all the needs of the person are met. To ensure a comprehensive and person centred care plan further attention to detail is needed. For example, One persons aim to promote independence is to be able to dress and wash appropriately. The plan of the day said, to shower, clean teeth, shave, and do laundry and to maintain own personal hygiene. This was more of list a rather then meaning person centred. The plan did not say, when this person preferred a shower or whether they had a wet or dry shave. There was no mention of choice or how this person preferred these things to be done. Records need to show how the person makes choices on a daily basis so individual choices and preferences are met by staff. Another care plan said to increase interpersonal skills, but did not say how. The care plan said to promote independence and to consolidate and build budgeting skills to increase the awareness of the value of possessions, but did not say how. This means the person will not get a consistent approach to their care An entry in daily records said the person could not have hot and cold drinks at the same time, but did not say why. Attention to detail is very important given the nature of the person’s cognitive impairment to maintain choice and preference. This information would have been establish during the admission process and should be transferred to care plans to ensure individuality is maintained. Risk assessments are completed whenever a risk is identified and these are monitored and reviewed. This enables staff to identify potential risks and assist the person to take risks in every day life in a structured safer way. For example: One risk assessment identified the possibility of violent behaviour. The person’s individual support had been kept under review. The behaviour guidelines index provided staff with an overview of how to support the person and included pro-active guidance to prevent situations and reactive guidance to respond to situations. It gave information on how staff should follow up and record information so interventions are monitored. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 14 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): 11,12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place, for socialising and activities to ensure the people who use the service experiences a meaningful lifestyle. EVIDENCE: The people who use the service are offered a wide variety of activities both within the home and in the community and are tailored to the individual needs of each person preferences. Each person has a weekly timetable that is a combination of both leisure and activities to help him or her develop independent living skills. Activities include cooking, ironing, shopping, meals out, swimming, church, gym, eating out, and social activities with family and friends, music, and drama session. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 15 One person has completed a course with learn direct, this enable the person to learn a skill and obtain employment. The person has already enquired about a voluntary work placement with the Birmingham Volunteer Bureau. Staff have assisted each person to access public transport via the ring and ride and obtain bus passes. One person is undergoing a series of tolerance drives to increase the amount of time spent in a car to be able to visit relatives a long distance away. One activity that had not been available to the people in the home was the right to vote. The manager confirmed this political activity needed to be addressed. During the visit staff interacted well with the people in the home. Conversations were directed towards them and staff engaged in one to one activities. Menus seen indicated that a range of nutritious and culturally appropriate food is provided. Service users are encouraged to shop and plan menus for the week. Some service users have a weekly budget, to enable them to shop for themselves and prepare meals of their choice. The dining room was nicely set out and the person who lives in the self-accommodating flat is free to dine with other the other people in the home. This enables all service users to socialise in pleasant surrounding and enjoy their meals. All meals planned are with the help of the people who live in the home, special diets are catered for as part of the persona assessed needs. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 16 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. Each persons health and personal care needs are met. The medication procedure needs to be further developed to fully safeguard people from potential harm, and to ensure they receive their medication as prescribed. EVIDENCE: Care plans are detailed giving good information on the personal support required to maintain independence. The preferences and choices of how the person wants their personal care to be delivered needs attention to detail. Four care plans were sampled, all service users had the same general practitioner, and it was not recorded if this was the person choice. The aims and objectives are completed on individual care plans to give information to staff of the personal care to be provided. This could be improved further detailing the preferences and personal choice of how the care 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 17 is to be delivered. For example: when a person has a shave is this a wet shave or does the person use an electric razor. Recording this information will ensure the care provided is personal to the individual. Health care notes indicated that service users are supported to attend routine G.P, dentist, chiropodist and optician appointments. There is good recorded information in care plans to say what a person needs to stay healthy and what healthcare services they need to access. Staff were observed using preferred terms of address and personal care is delivered in the privacy of the persons bedroom, to preserve their dignity. The home works closely with a multi disciplinary team to monitor the placement of each individual person due to their complex needs. This ensures communication is consistent and the care provided is in the best interest of each person living in the home. The medication administration records (MAR) cross-referenced with the blister packs indicating medication had been given as prescribed. Only named staff are permitted to give medication that has all received training in the administration of medication. On the day of the inspection an audit of boxed medication such as Paracetamol showed there was less quantity then the MAR chart indicted. This was a result of staff not signing adequately the date the medication was received on the administration record (MAR charts), so a robust audit could not be completed. When staff apply a prescribe cream this is not being recorded to say this has been applied. The management of the blister pack was acceptable. The home has a list of homely remedies that can be given to service users, this needs to be signed by a general practitioner with robust guidelines to ensure the people living in the home are not placed at risk from adverse reactions when taking prescribed medication along side homely remedies. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and relatives are confident that their views will be listened to and any complaints dealt with effectively. Staff knowledge and written procedures indicate that service users are protected from the risk of abuse. EVIDENCE: There is a clear complaints procedure and policy that give the details of timescales a complaint will be responded to and who to contact. The AQAA (Annul Quality Assurance received by the commission states, all staff are aware of the complaints policy but does not state all service users are aware of this policy. The manager said each service users has a copy and a copy is displayed in the unit. It is unclear how service users would use this resource given the nature of their cognitive impairment. The manager said “ at each review or when staff are with service users at present the staff would raise their concerns however alternative measures are being looked at. It was pleasing to see the home had recognised the important of service users be able to fully understanding the procedure to take in the event of a complaint and the possibility of abuse. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 19 The home has included this in the development plans in the next twelve months and is looking at alterative formats of the complaint procedure and adult protection policy such as audio- visual, large print and pictorial to ensure all service users understand how to complain. The home uses the Birmingham Multi Agency Guidelines for adult protection that includes a whistle blowing policy. Each service user has been issued with an easy to understand document as part of their assessed needs, entitled say no to abuse that is displayed on the notice bored in the home. One relative said “ I have no concerns, I know any complaint would be dealt with, the staff are very friendly the management is good so I have no worries’’. The home has not received any complaints since registration and none have been forwarded to CSCI. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with warm and comfortable safe home to promote their well-being and individual needs. EVIDENCE: The building is purpose build to provide residential care for people with acquired brain injury and is cleaned to a high standard. There is access to the front of the building for wheel chair users via a ramp. This ensures there is no restriction in entry to the building. The laundry facilities include two domestic washing machines and one tumble dryer to enable staff to assist service users to do their own washing. The kitchen facilities are accessible for wheel chairs users with an accessible hob and domestic oven. Each person is provided with a cupboard in which to store their grocery supplies when they go shopping. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 21 It was evident that service users had made decisions about what they wished to have in their bedrooms by how each bedroom was personalised. It was not clear if service users participated in the décor of their own bedrooms but decoration plans as identified by the home to be implemented should incorporate a choice for each individual to be involved in the décor. This will ensure service users have a choice of what their room will look like in the future. A parker bath is available if assisted bathing is required’ and there is ample toilets around the home. Other aids and adaptation are provided based on the assessed needs of the individual when required. COSSH (Control of Substances Hazardous to Health) items are stored in a locked cupboard to prevent risks of injuries to service users. The home is comfortable, well maintained and secure to ensure the safety of the people who use the service. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for staff training their development were variable which could impact on their ability to consistently meet the needs of the residents. Recruitment practices are robust and therefore protect service users from harm. EVIDENCE: The home was able to provide training details demonstrating staff training in mandatory areas, such as first aid, manual handling, health and safety, food hygiene, adult protection and administration of medication. As this is a new service not all staff have completed mandatory training in all areas, however the home has a training matrix that demonstrated training was planned in the near future. Staff were able to demonstrate in discussion their knowledge and training, and observations of staff interacting with service users showed they had a good knowledge of their needs. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 23 Not all staff has successfully achieved NVQ level 2 in the relevant area of meeting the complex needs of the service users. The home has recognised there is a need for further development in training staff that is specific to brain injury this will enable staff to have more knowledge and understanding about brain injury. The future development plans includes registering staff on NVQ programmes, and to consult a neurophysiologist to develop training in the specialist area of brain injury. This will enable staff to gain further knowledge and understanding of the person needs The service ensures a mix of staff to meet the needs of each person. A full induction takes place that is in line with skills for care, which ensures all aspects are covered to enable staff to have adequate knowledge of their roles. The three staff files examined revealed that all necessary checks are carried out before employment is commenced, such as references, application forms, medical clearance previous employment history, education and experiences. POVA (Protection of Vulnerable Adults), CRB (criminal Records Checks) are all completed this safeguards the people who use the service. Supervision is completed regular to ensure staff are supported in their role. There was no evidence that staff have a personal development plan. This will ensure their own personal development in training and meeting their own aims and objectives. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 24 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 registered manager has good vision for the development of the home and staff have clear lines of accountability. The Health and Safety arrangements ensure that residents are protected from harm and live safely in a home that is well run. EVIDENCE: The manager is experienced and possesses the skills to oversee the day-today management of the home. Observations of the manager and deputy manager indicated that there was a transparent approach to service users and delegated tasks to staff in a constructive manner. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 25 There is an ongoing plan to improve the service further. The manager and staff have worked had to meet the National Minimum Standards. There are a number of areas to improve on and it is pleasing to see that the home has recognised these as part of their future plans to provide better outcomes for the people who live in the home. The involvement of service users in all aspect of the running of the home is hindered by their cognitive impairment, however they are involved in the recruitment process, attend regular meetings, are supported to maintain family links and have an active social life. Health and safety of the home is monitored and reviewed, these include checks on equipment, servicing of equipment, fire drill, tests and risk assessments. The inspectors did not look at all the policies and procedure as these would have been available before registration. 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 26 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 3 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 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 27 New service 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 YA6 Regulation 12(3) Requirement Care plans need attention to detail and must show how the needs of each person are met on a daily basis. This will ensure the changing needs of the person are monitored to ensure their goals and aspirations are met. Care plans must show how choice and preference are made by the individual to ensure to ensure it is the service user choice and not the choice of staff. This will ensure the person rights to individuality are maintained. Robust medication procedures must be followed to ensure the safety of the people using the service. All staff must receive suitable training within a given time scale to ensure the people who use the service are fully protected. Timescale for action 01/09/07 2 YA7 12(2)(3) 01/09/07 3 YA20 13(2) 01/09/07 4 YA32 18(8) 18(c)(i) 01/09/07 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 28 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 YA35 Good Practice Recommendations It is recommended staff receive specialist training specific to the people who use the service. This will ensure staff have the knowledge and understanding about brain injury and be able to implement their skills when assisting service users. It is recommended management and staff ensure people are given the opportunity to maintain their political rights. This will enable each person to have a choice whether they wish to vote. 2 YA13 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Regional Office 1st Floor Ladywood House 45-56 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 1101 Bristol Road DS0000068462.V342074.R02.S.doc Version 5.2 Page 30 - 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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