Inspection on 19/08/05 for 15 Hulse Road

This inspection was carried out on 19th August 2005.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

15 Hulse Road 27/09/06

15 Hulse Road 27/01/06

15 Hulse Road 11/03/05

15 Hulse Road 10/09/04

15 Hulse Road 01/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hulse Road (15) 15 Hulse Road Salisbury Wiltshire SP1 3LU Lead Inspector Tim Goadby Unannounced 19 August 2005 th 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 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 Stationary 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. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hulse Road (15) Address 15 Hulse Road Salisbury Wiltshire SP1 3LU 01722 326490 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap (Housing & Support Services) Mencap National Centre Tracy Piper Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number PD Physical Disability (2) of places Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users in the age range 18 to 64 years who may be accommodated in the home at any one time is 6. 2. No more than 2 service users in the age range 18 to 64 years may have both a learning disability AND a physical disability. 3. The Commission must be advised of any circumstances when named service users are unable to access first floor communal space. 4. The Commission must be consulted if it is decided to use the communal space area for staff sleeping in and give prior approval for such a change. Date of last inspection 11th March 2005 Brief Description of the Service: 15 Hulse Road provides care and accommodation for up to 6 adults with a learning disability. Up to 2 service users may also have a physical disability.The service is operated by Mencap. This is a national voluntary organisation working in the learning disability field. They have a number of care home and supported living facilities throughout Wiltshire. The home is located within level walking distance of the cathedral city of Salisbury. It is close to a range of amenities. These include shops, a cinema, a theatre, and a leisure centre. The building is an older property, located in a residential area. It has been extended on the ground floor. Service user accommodation is arranged over 3 floors. There are 4 single bedrooms, and one that is shared. 3 of the bedrooms have en-suite facilities. Ground floor accommodation is available for any service users with some degree of physical impairment. There is no lift in the home. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in August 2005. The visit was conducted in the late afternoon and early evening, to ensure that there would be an opportunity to meet with all service users. A total of 4.25 hours were spent in the home. The following inspection methods have been used in the production of this report: direct and indirect observation; sampling of records, with case tracking; sampling a meal; discussions with service users and staff; tour of the premises. What the service does well: 15 Hulse Road is an established service which has undergone a period of change. 2 longstanding service users left the home a year or so ago, and these vacancies have both been filled by new individuals, with differing needs. There has also been a period of staff turnover, meaning that many of the current team are relatively inexperienced. The service has coped well through this period, and has continued to deliver care and support effectively to its user group. A significant element of this has been an excellent admission process. For both the recent arrivals, records show a thorough approach at each stage. Full assessment information has been gathered. There has been detailed consultation about possible moves with all relevant persons, including the prospective service users and their families, and the existing residents of the home. Trial visits have been carried out carefully, with suitable guidance in place to assist with the success of these. Following admission, systems for developing and reviewing the care to be provided have worked well. Support to service users was observed to be delivered patiently and respectfully, and in line with the current guidance in sampled care plans. In particular, support to one individual over mealtime, which was clearly a challenging task, was given calmly and consistently. As at previous inspections, the service was found to perform strongly in promoting quality of life for its users. There is a clear focus on encouraging people to maintain and develop skills, enabling them to be as independent as possible. A range of experiences and opportunities are offered, including regular access to community activities. Support for key health care needs is another area of strength. Sampled records showed that the home works with service users to ensure that they Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 6 have access to all the advice and treatment they need. This has brought clear benefits in health improvements for some individuals. All 6 service users were present during this inspection. They appeared settled and confident in their surroundings. Interactions with staff on duty were friendly and relaxed. People were seen to be contributing fully to all the various happenings in the home. Those service users with speech were able to talk about the various things they have been doing, and expressed enjoyment about their quality of life. 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. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 4 Admission processes are thorough, ensuring that new and existing service users can make informed choices about moving into the home. Service users have their needs and aspirations met. EVIDENCE: Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 9 The needs of prospective admissions are carefully looked at. Their compatibility with existing service users is also considered. People living at the home are consulted for their views about the person who might be moving in. There have been 2 admissions to the home over the past year. In each case the process had been carried out appropriately. Records showed an excellent level of clear information had been developed during pre-admission assessments. Both individuals had undertaken a number of trial visits. Records were kept of how these had gone. Relatives had also visited, and been given key information about the home. Initial care plans and risk assessments were put in place, to enable effective support to be given during trial visits. Once the service users moved in, there were suitable arrangements in place to keep the success of the placements under review. Both individuals now seemed well settled in the home. 15 Hulse Road does not cater for emergency admissions. With the recent admissions, the mix of abilities and needs amongst Hulse Road’s user group has changed. The service appears to have coped well in absorbing the impact of these changes. The needs of all users are being met. Staff have received training in relevant topics. In addition to the support provided by the home’s own team, the input of other relevant agencies is accessed as needed. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users’ needs and goals are reflected in their individual plans. Service users make choices and decisions in their daily lives. Service users are supported to take risks and access opportunities. EVIDENCE: All service users have detailed care plans, covering all aspects of their lives. Sampled plans at this inspection showed that there has been continuing progress in developing the scope and quality of these records. There was clear information about separate areas of need, with precise guidance for staff on how to support each of these. The reasons for support were explained, and the input of various relevant people in devising guidelines was also shown. The home promotes the involvement of all staff in producing care plans. Staff are allocated as keyworkers for individual service users, and will then have input into the documentation for that person. Service users contribute to defining the goals they wish to work towards. These are then broken down into achievable stages. There is ongoing review Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 11 and evaluation of progress. The home works with its users to promote their independence and autonomy. Any limitations are clearly linked to assessments and care plans. Review meetings for individual service users are held at differing frequencies, depending on their needs. There is ongoing review of care within the home, between these formal sessions. Sampled records showed that reviews were up to date. There is a clear process for risk assessment. These are carried out for a wide range of topics. Risk taking is promoted where appropriate, with any necessary safeguards in place. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Service users have opportunities for personal development. Service users have regular opportunities for appropriate activities, both at home and elsewhere. Service users are able to maintain and develop key relationships with family and friends. Service users are supported to plan and prepare appropriate meals. EVIDENCE: Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 13 Communication styles and abilities vary amongst the service user group. Some are able to use speech. Others rely more on signs, symbols and pictures. Various information is presented in ways that are accessible to the different individuals. Staff receive training to enable them to communicate as effectively as possible with each person. Skills assessments are documented. These show service users’ abilities and needs in key areas of daily living, such as personal care, cooking, cleaning, and money management. People are regularly involved in these tasks, which are allocated on a rota basis. On the day of this inspection, residents were observed participating fully in cleaning, cooking, washing up, and ironing. They also answered the door, and phone calls. The maximum degree of independence was promoted, with some monitoring and support from staff if this was assessed as necessary. Most service users have a full daily programme during the week. This includes attendance at local day centres and clubs. Some are also studying at the city’s college, and were due to re-enrol in September, when it reopened. When people do not have programmed activities outside the home, they are supported by Hulse Road’s own staff. The weekly timetable for each individual is on display in the kitchen. People can fill their leisure time in a variety of ways at home. They also have active social lives. Individual interests and preferences are recorded within care plans. Regular outings include the cinema or theatre, shopping, or going out for a meal. These are supported by staff, as necessary. Service users either walk, use public transport or take a taxi. Service users all receive the opportunity to have an annual holiday. They are involved in choosing the destinations for these. Various photographs are displayed in the home, showing the places people have visited. At this visit, service users spoke about the holidays they are due to go on this year. It was clear that they were looking forward to these. Wherever possible, the home actively supports service users to maintain contact with family and friends. Visitors are welcome to Hulse Road at any reasonable time. Some people regularly go to see their families. Staff support service users to send presents and cards for family birthdays. A number of residents have close friendships with people they have lived with in the past. Care plans include information about key relationships for each individual, and how they are helped to maintain these. The home is also working to try and widen the circle of friends and acquaintances for its user group. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 14 People are provided with keys to the front door, their own bedroom, and a lockable space, if they wish to have these. The home has an agreed no smoking policy. Anyone wishing to smoke may only do so in the garden. All service users participate in meal planning and preparation. They assist staff in shopping for ingredients, and with cooking. Menus are chosen by the service users, usually a day in advance. Once the choice has been made, it is displayed in symbol form. Staff work with service users to encourage a balanced diet. Some people have been losing a little weight, to help with their overall health. During this unannounced visit, the inspector was invited to join the household for their evening meal. This was taken together, with staff and service users eating alongside one another. Mealtime support was seen to be given patiently and respectfully, in line with the guidance in care plans. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 standard(s) 18 & 19 Service users receive effective support for their personal and health care needs. EVIDENCE: The amount of personal support required by service users varies. Descriptions are contained within care plans. Staff tailor their approach accordingly. Independence is promoted wherever possible. People choose their own clothes, during shopping trips with their allocated staff keyworker. Until recently the home had an exclusively female service user group. There is now also a male. The majority of staff are female, but some male relief and agency workers have been used, to ensure some male contact for this individual. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 16 Evidence on sampled service user files showed that there is effective support for a range of health needs. All service users are registered with their own GP. When needed, they attend appointments in the normal way. Other healthcare support is accessed as required. Records are kept of all such contacts. Professionals involved over recent months have included a psychologist, speech therapist, occupational therapist, and physiotherapist. One of the most recent admissions came to Hulse Road, in part, because of concerns regarding their physical health. The service has been successful in bringing about improvements on some key issues, to the benefit of this individual. Further input was being pursued. For the newest admission, records showed that there was effective consultation with a range of relevant professionals in devising suitable care guidelines for key needs. These contacts were ongoing, and there had been recent requests for further advice, in response to identified changes. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 standard(s) EVIDENCE: These key standards will be inspected at the next visit, which is due not later than 31st March 2006. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 18 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 standard(s) 24, 25, 27, 28, 29 & 30 Service users live in a comfortable and homely environment, which is kept clean and safe. EVIDENCE: 15 Hulse Road is located at the end of a quiet residential street, close to the centre of Salisbury. The accommodation is spread over 3 floors. The premises are domestic in scale. They are attractively decorated, and appear well maintained. Responsibility for the majority of maintenance issues rests with the housing association that owns the property. Since the previous inspection, some new furniture had been obtained, including a dining table and chairs. Service users reported that redecoration of some rooms is planned shortly, and that they had been involved in choosing colour schemes. Bedrooms are provided on all 3 floors of the home. There are 2 ground floor rooms. Both of these have en-suite showers and toilets. The shared bedroom Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 19 is on the second floor. This has an en-suite toilet. The remaining 2 bedrooms are on the first floor. The shared room has curtained screens, which afford some privacy. The 2 people sharing this room have done so for a number of years. The inspector was invited to see it by 1 of its occupants. The bedroom was comfortably furnished, and had recently been attractively redecorated. There was a clear division between the areas allocated to each person. In addition to the en-suite facilities already described, there is a bathroom on the first floor. There are also toilets on both ground and first floors. The home’s main lounge and dining area are at the rear of the ground floor. The kitchen also has space for a table with seating. The home has recently created extra communal space, by de-registering a first floor bedroom. This has become a second lounge, which can also serve as a private meeting area. The intention is for this to be more of a quiet space, where people can relax. A condition has been set that all service users should be able to access this room, to ensure that it can reasonably count as part of overall communal space calculations. The office, which doubles as a sleep-in room, is on the first floor. Space in this area is limited. It is likely that the additional lounge may also become the sleep-in room, through the use of a sofa bed. Care would need to be taken to ensure that this did not unduly restrict its use by service users. The home is required to consult again with the CSCI, and obtain prior approval, before implementing such a change. There is a large garden to the rear of the property. This has a patio and an area of lawn. One of the service users is particularly involved in helping to maintain the garden. The home is registered to care for 2 people who may have physical impairments, in addition to a learning disability. The possibility of offering ground floor accommodation for such service users enables this aspect of care to be provided. Various adaptations and equipment have been provided within the home. Examples include fitting grab rails by the bath; and having lever handles on taps, for easier operation. Staff at the home are responsible for the cleaning. Service users also participate, in keeping with their abilities and wishes. The home was found to be clean and hygienic in the areas seen at this unannounced inspection. One Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 20 service user was engaged in the weekly cleaning of their own bedroom, and carried this out independently, and with great thoroughness. Similarly, another service user carried out comprehensive cleaning of the kitchen after the evening meal. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Staff are provided in suitable numbers to meet the needs of service users. EVIDENCE: Rotas are drawn up in line with the weekly routines of service users. There are always at least 2 staff present during daytime hours, when all service users are at home. This enables 1 or 2 people to go out at a time. Numbers can vary. For instance, only 1 staff member may be needed if there are fewer service users, such as at weekends, when some people may visit their families. Or more staff may be provided, to enable service users to undertake activities. Cover is maintained by the use of relief or agency workers, when necessary. On the day of this unannounced inspection, 2 staff were on duty. One was due to finish at 21.00, which would then leave the other person to cover the overnight sleep-in. The newest service user currently has noticeably higher support needs than the rest of the group, meaning that this individual is more likely to require periods of 1 to 1 support from staff. For instance, intensive input was needed by this person over the mealtime period. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 22 Hulse Road has experienced a period of staff turnover. The majority of the team now in post have been working at the home for less than 2 years. Turnover had continued since the previous inspection, in March 2005. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41 & 42 The registered manager is suitably qualified and experienced, so that service users benefit from a well run home. The home has failed to notify some significant events to the CSCI, as required by care homes legislation. Suitable steps are taken to ensure the health and safety of service users. Some attention is needed to specific guidance concerning mobility and falls prevention. EVIDENCE: The home’s registered manager is Mrs Tracy Piper. She works as part of the care team, in addition to her administrative and managerial responsibilities. Within the home, she is supported by a deputy manager. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 24 Mrs Piper has completed the Registered Manager’s Award qualification. The deputy manager is also currently undertaking NVQ Level 4 training. Organisationally, there are clear structures within the regional Mencap team. Senior managers have set responsibilities in relation to the service. There are good communication channels and support systems in place. Not all statutorily required records were checked during this unannounced inspection. Those sampled were maintained to a good standard. But the home had failed to report some significant events to the Commission when they occurred. 2 examples were seen in the records checked during the visit. Firstly, an incident when a service user who needs support outside the home in respect of mobility and road safety had fallen; and secondly, a recent refusal of medication by the same individual. In both cases, the home’s own records indicated that the events had been managed effectively. But notification should also have taken place. Health and safety arrangements are appropriate. A wide range of risk assessments and guidelines are in place. These cover both general topics, and those relating to individual service users. Staff receive training on all mandatory topics. This is updated at the necessary intervals. The fire log book was checked during this unannounced visit. All required checks and instruction were recorded as being carried out, and up to date. The risk assessment had been reviewed in January 2005. Procedures clearly set out the response required if a fire is discovered, or the alarm system is activated. Practices are held regularly, and these include service users. A record is kept of how each individual has responded. Some people have hearing impairments, and they have been provided with additional devices to alert them that the alarm is sounding. Staff confirmed that they receive training in moving and handling, and that this has included specific guidance on supporting individual service users. One person has particular needs relating to mobility, and falls prevention. Risk assessments and management guidelines are in place. One element of these would benefit from review. Staff are instructed to follow the individual upstairs, and lead them down, due to the risk of a fall. But the guidance is not developed further, to explain what they should do if the person does so. Staff confirmed that it was their understanding that they would not try to catch the service user, as this could present further risks. The guidance needs to be reviewed, and the actual approach made clearer. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 3 4 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hulse Road (15) Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x 2 3 x D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 26 No 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 YA41 Regulation 37(1)(e) Requirement The persons registered must notify the Commission without delay of any event which adversely affects the safety or well-being of any service user. Timescale for action From 19/08/05. 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 YA42 Good Practice Recommendations Risk management guidelines for mobility and falls prevention should be reviewed to ensure that they contain clear and precise guidance on staff interventions. Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 27 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire SN15 2BB 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 Hulse Road (15) D51_D01_S28695_HULSERD(15)_v191483_260805_Stage4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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