Inspection on 11/09/07 for 16 Cleeve Hill

This inspection was carried out on 11th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

16 Cleeve Hill 23/10/06

16 Cleeve Hill 25/10/05

16 Cleeve Hill 09/05/05

16 Cleeve Hill 19/10/04

16 Cleeve Hill 21/04/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 16 Cleeve Hill Downend South Glos BS16 6HN Lead Inspector Grace Agu Key Unannounced Inspection 11th September 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Cleeve Hill Address Downend South Glos BS16 6HN 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) 0117 957 0839 0117 970 9301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Jane Mary Ireland Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 18 years and over. May include persons aged 65 years and over 23rd October 2006 Date of last inspection Brief Description of the Service: I6 Cleeve Hill is a home for 5 people; it is part of the Aspects and Milestones Trust. The home was opened eight years ago as part of a programme of developing residential community care, for former patients of Stoke Park Hospital. 16 Cleeve Hill is a mature bungalow, which has been renovated and extended to provide accommodation on one floor. It is located on a busy road in a residential area of Downend: shops, post office, library and other amenities are approximately two hundred metres away. There are regular bus services to the centre of Bristol and there is easy access to the motorway network close by. The home provides residential care for people with learning difficulties. There are a variety of daily activities for service users which are supported by the staff and day care support services provided by Spectrum, (which is part of Brandon Trust), and the local day centres. The home has recently leased a vehicle in order to enable service users to fully access community facilities. Fees range from £1098 - £1106 per week. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which was undertaken as a part of key inspection over seven hours and was undertaken to review the requirements made at the last inspection also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection one requirement was made in relation to reviewing the risk assessments following accidents to two individuals at the home. This was to enable staff to ensure that the people who use the service are protected from harm and potential injury. It was pleasing to note that the requirement had been met. I met with Ms Jane Ireland, the home manager and two support workers. A brief tour of the building was undertaken to look at the general maintenance of the home to ensure that it is comfortable for the people who use the service. We spoke with one resident and staff. A number of records were viewed. What the service does well: Generally, the home was found to be clean, warm, and homely and the residents looked relaxed and well cared for. The atmosphere at the home on the day of inspection was friendly, staff were helpful and informative and were seen interacting with residents. Staff showed awareness and sensitivity in the way a person with challenging behaviour was supported on the day of the visit. The home has an effective communication system that enables staff and supporting services to deal with the challenging needs of people living there both within and outside the home. This was evidenced by clear documentation of when an individual presented with difficult issues and how staff managed the situation. Relatives of those who use the service told us in the survey that from everything they see when they visit 16 Cleeve Hill that “everything is done to a very high degree of comfort, cleanliness and quality care”; 16 Cleeve Hill is a well run home, we are well pleased with the atmosphere and outings that are planned. The home told us in their Annual Quality Assurance Assessment the long-term knowledge, experience and skill of staff enables them to communicate with the people living at the home to provide them with quality care. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 6 During the inspection observation and review of various records led us to believe that there is a high quality care planning system which is person centred and specifies how identified needs were being met. The care plans were regularly reviewed to accommodate the changing needs of the persons living at the home. The home ensures that aids and equipment are provided to assist staff with meeting the needs of the service user where applicable. We are also able to say after observing lunch that good and nutritious meals are provided for service users in a relaxed atmosphere and are not hurried. People living at the home who are not able to feed themselves are fed in a sensitive and dignified manner. What has improved since the last inspection? What they could do better: One individual using the service would benefit from better care and the needs would be met if staff received challenging behaviour training. The knowledge that staff would acquire would enable them also to develop ways of reducing the impact that the challenging behaviour would have on other persons living at the home. Whilst reviewing medication administration it was noted that a prescribed medication had no clear instruction (as directed) in relation to its application. This practise potentially puts the person at risk of medicine error. Staff administrating medication must have clear instructions from the pharmacy to ensure that the people who live in the home are protected. The procedure for using lifting equipment for a person living in the home must be reviewed following an accident during this procedure. The individual would be adequately protected and the risk of injury to the individual and staff minimised. The manager informed us that contact had been made and that the Occupational Therapist had been booked to visit and review. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 7 Whilst there was a risk assessment to prevent accidents and injury to an individual living at the home, this risk assessment was not reviewed following a recent accident. This practice potentially puts the person at risk. The home must ensure that this review is carried out to ensure that the person is adequately protected. 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. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there have been no new admissions the home has a detailed, wellplanned and comprehensive admission process to enable any prospective service user to make an informed choice of moving into the home with the assurance that the individual’s needs would be met. EVIDENCE: Review of records, discussion with the home manager and observation of the people that use the service we are satisfied that the home is able to meet the assessed needs of the individuals living at the home and any prospective individuals who may seek admission in the near future. There have been no new admissions to the home for some time. People who use the service seen on the day seemed happy and well cared for. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from care and support throughout their lives and towards the end of their lives. However the home fails to adequately support an individual through lack of care plan for identified need. Lack of risk assessment review following accidents puts the individual at risk. Medication administration is satisfactory. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 11 EVIDENCE: People who live at 16 Cleave Hill have high level of needs and require different levels of individual assistance tailored to meet their needs. One care file of a person who uses the service was reviewed at this inspection. The information found was comprehensive, detailed, person centred and holistically focused. The information recorded was to assist and equip staff with providing support in areas of personal, emotional, social and physical care based on the service users individual circumstances. Other information noted in the care files included, personal information containing: next of kin, General Practitioner, support for daily living, places I like to go,’ personal preferences, other likes and dislikes, annual medical and social services reviews summary of activities and community visits. This information will provide staff the knowledge required to meet needs of the individuals’ living at the home. Included in the care file are care plans on how the emotional physical and social needs of the individual were being met. The care file also had evidence of visits from other health professionals to include General Practitioner (GP) Consultant Dentists, occupational therapists, physiotherapists and opticians. There was evidence of a recent consultant psychiatrist visit to review the medication and health needs of the individual. There was evidence of risk assessments in place in relation to bathing, washing, mobility, personal hygiene and using a specialist chair. Staff spoken with demonstrated knowledge and understanding of individual service users’ needs, including support for emotional needs. However records seen showed that the procedure for using lifting equipment for an individual with complex needs was not reviewed following an accident. Furthermore records from the accident book showed that another individual’s risk assessment was not reviewed following an accident. The manager stated that contact had been made with the Occupational Therapist (OT) and an appointment had been made for a visit to review the procedure. This would be reviewed at the next inspection It was also unsatisfactory to note that there was no care plan in place to demonstrate how an individual with challenging behaviour was being supported following recent incidents. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 12 Through observation on the day of the visit, it was clear that the individual was agitated and needed a strategy to enable staff to provide appropriate care to meet the needs of this person and to minimise the impact the behaviour may cause to the health and safety of other service users. An assurance was given by the manager that a care plan would be put in place immediately to meet this need. This would be the focus of the next inspection. Requirements made in relation to issues identified above to ensure that the people who use the service receive the care that they deserve were therefore withdrawn. Three relatives comment cards received before the inspection confirmed that they were satisfied with the care and services provided for their persons at the home. One new staff spoken with on the day showed understanding and knowledge of the individual needs of people who use the service. The staff member clearly identified the most important values that uphold and promote good care at the home. These include respect, dignity and privacy. The system for recording, handling, safe keeping, safe administration and disposal of medicines was reviewed. A local pharmacy provides medication using a weekly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All other medication seen was stored securely. The home has a medication policy; the manager explained that all the support workers working at the home have received training on medication administration. To ensure safe administration all prescribed medication must provide clear instructions on how the medication is to be applied in order to protect the resident. There have been no deaths at the home for a long time. The home has a policy in relation to how to support residents when unwell due to terminal illness and at the time of death. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides meaningful activities to people living at the home, enables them to maintain contact with families and friends and ensures that choice is provided in respect of meals and meal times. EVIDENCE: Each person living at the home is supported to participate in the activities of their choice, have individual plans for activity depending on their risk assessment. The manager stated that four service users attend activity sessions provided by Brandon Trust. One individual was attending daycentre at Blackhorse RAC, Mangotsfield on the day of inspection and four days a week. Another two persons were supported by care workers from Brandon trust to go out on a planned activity in the community. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 14 People who remained at the home were seen doing jigsaws and relaxing in the home and interacting with staff. The manager stated that three individuals were supported to enjoy a short break in Devon in March 2007 and another holiday has been planned for all the ladies on 30/09/07. Risk assessments were in place for all activities undertaken by individual residents. Whilst there were no visitors met at the home on the day of inspection, the relatives and friends of people who use the service told us in the survey that they visit quite often; one relative stated “16 Cleeve Hill is a well run happy home. I visit every other week, and come home well pleased with the atmosphere and outings that are planned”. Another relative stated, “ I visit every week and we are very pleased with all that is done”. There was evidence of visits in the visitors’ book viewed. Using their skills, experience and knowledge, staff are able to assist and support residents with communication problems to choose what they would like to eat. The manager stated that the menu is planned around the individuals based on individual preferences. Staff ensure that one individual who has diabetes has a nutritionally balanced diets whilst ensuring that the condition is kept under control as much as possible. Residents were noted being consulted for choices of meal for lunch and were seen being supported to have their meals at lunchtime, the meal was relaxed. Two residents spoken with said that they enjoyed the meal. The resident who was unable to feed her/him self was supported and fed in a respectful, sensitive and dignified manner. The kitchen was found to be clean; the fridge and freezer temperatures were regularly recorded. Risk assessment was in place to protect staff and residents. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to complain and are confident that the home is able to protect them from abuse. EVIDENCE: Evidence from the complaints log book and surveys from relatives, show that there have been no complaints since the last inspection, furthermore no complaint was received at the Commission for Social Care Inspection about the services provided at the home since the last inspection. The home has a complaints policy and procedure from Aspects and Milestones. There was a copy of this document in each individual user’s care file. This was produced in a picture format, to make it relevant to the people living at Cleeve Hill. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 16 Staff spoken with demonstrated knowledge of how to enable service users to complain. There was evidence in the care file that the complaint procedure is explained to the individual. Evidence from staff records and discussion with staff showed that they had attended abuse training. The home also has policies on Abuse of Vulnerable Adults to provide them with the guidance on how to recognise and report any suspected abuse in order to protect the people living at the home. Staff records viewed contained evidence of Criminal Record Bureau disclosure to ensure that only staff with integrity are allowed to support the individuals with that level of need. A Whistle blowing policy is also available to enable staff to report bad practices without fear of reprisal. One service user spoken with said that she felt safe at the home. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,2125,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a safe, clean, well-maintained environment, comfortable bedrooms and specialist equipment suitable for the needs of people who use the service. EVIDENCE: 16 Cleeve Hill is situated in the residential area of Downend. All the areas of the home are accessible to the people who use the service and their visitors and have ramps and rails to the front and back of the house. The home was found to be clean, tidy and free from offensive odours. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 18 The lounge /dining area had recently been redecorated and a new set of furniture purchased to make the home more comfortable for the individuals living at the home. The manager stated that refurbishment of the home will continue whilst the people living at the home are on holiday in order to minimise disruption to their daily routine. All bedrooms viewed had single occupancy, were personalised, colour coordinated and well furnished. All service users had a sink in their bedrooms for their own private use. The toilets and bathrooms had grab rails, manual handling equipment, hoists, and a specialist high low bath to assist staff with meeting needs of the individuals. One individual has a hospital bed for use in order to support them with a medical condition and assist staff with meeting the individual’s need. Risk assessment in relation to this individual had been discussed under Standard 8. There is ongoing maintenance at the home. All work to be carried out is recorded including when it was completed. The laundry was found to be clean with good flooring, adequate ventilation and was accessible to service users who may be supported by staff to do their own laundry. The manager stated that the laundry might be moved to a room with bigger space to accommodate the new washing machine recently purchased to provide the individuals living at the home with better laundry facilities. A risk assessment was in place at the kitchen and laundry. A generic risk assessment was in place in areas such as the bedrooms and the lounge and other areas that service users have access to, to ensure that people who use the service are adequately protected from hazards. The home had Control of Substances Hazardous to Health (COSHH) and Infection Control policy. This is to provide staff with guidance on how to protect the people who live at the home, staff and visitors from infection and hazardous chemicals. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that there are adequate staff numbers of skill mix and competency along with training to protect service users. However it fails to provide staff training on challenging behaviour. EVIDENCE: On the first day of inspection, there were three staff on duty, to include one Registered Nurse, for four service users with learning disabilities. One service user was attending the day centre until about 1600hours. Reviewing of staff records showed that staff have attended various training updates to include manual handling, Protection of Vulnerable Adults from Abuse, First aid, fire safety, basic food hygiene, epilepsy awareness and Control of Substances Hazardous to Health. The manager stated that four home support workers have completed NVQ level 3, one home support worker is undertaking NVQ level 3, and one home support worker is to commence NVQ at level 3. The registered manager, deputy manager and senior support worker recently attended a conference on different aspects of Essential Life Styles (ELS) and Person Centred Approaches (PCA) to equip them with the knowledge that they would require in order to provide good care to the people in that category. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 20 The manager is to commence an Information Technology course shortly. This course would enable the manager to have the necessary knowledge and skills to access information from the company’s system and the web in relation to caring for older people. Discussion with one staff member evidenced that staff have a range of skills and experience to enable them to meet needs of people using the service. The staff member also demonstrated understanding and knowledge of the individuals’ need and staff roles in the home. There was good interaction between the staff and the service users, which led us to believe that there is a positive relationship between the staff and the people who use the service. Relatives of people living at the home told us in the survey that they are satisfied with the services provided at the home. Examples of what they told us include; “Staff work well as a team, work for the needs of the residents, very organised, interested in the residents, friendly approach”. “From what we see at 16 Cleeve Hill everything is done to a high degree of comfort, cleanliness and quality care.” In relation to staff recruitment Aspects and Milestones have a recruitment policy, which was seen, at the last inspection. There was evidence of required recruitment documentation in the care files of two recently employed staff members to ensure that the people living at the home are protected from bad practices. It was agreed that staff working at the home must attend challenging behaviour training update (the manager stated that the last training was about five years ago) in order to equip them with recent information regarding the care of the people who live at the home. The staff member spoken with on the day stated that they were provided with good induction and in-depth training about the needs of the individuals living at the home. Existing staff members were very supportive and enabled the individual to learn at their own pace until they are confident to assist the people living at the home independently. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33.36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership, and management, its practices protect the health and safety of the people who use the service. EVIDENCE: A well-qualified and competent manager who has been at the home for many years manages 16 Cleeve Hill. The registered manager is a Registered Nurse for Leaning Disabilities (RNLD) and has attended many training courses to enhance her knowledge and skills to enable her to provide quality care for the individuals living at the home. The manager has achieved National Vocational Qualification (NVQ) level 4 in management. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 22 Staff spoken with on the day of inspection made positive comments about the manager and the organisation. One staff member stated that she gets on well with the manager and that the manager is very good and very approachable. Three relatives comments cards received before the inspection contained evidence of satisfaction with the care to the people who use the service. One-comment card states, “16 Cleeve Hill is a well run home”. The manager stated that she is happy at the home and that she is regularly supervised and supported by her line manager. Evidence from the staff records at the home showed that staff receive supervision regularly and are supported to perform their duties effectively in order to meet the needs of the people who use the service. The home has different ways of monitoring its quality of service. This includes, provider’s monthly visits, regular review of care plans along with regular contact with service users’ relatives and friends. The home has a monthly monitoring form for all aspects of the services provided including health and safety issues. The manager stated that the Trust has developed a quality audit tool with the Commission for Social Care Inspection focusing on the outcomes for the people who use the service based on the National Minimum Standards for different services. The audit tool is used by a manager from a different home to look at the services provided in a home and provides the manager with feedback in order to improve the service. The document was seen and the inspector noted the action plan to meet the issues raised. Individuals’ money monies held at the home tallied with the records seen. There are comprehensive policies and procedures provided by Aspects and Milestones at the home. Staff were able to demonstrate knowledge of where these were kept. Policies seen include Complaints Abuse Communication and Missing persons. Information noted on the policy book stated that these policies are under review to enable staff to be up to date with what they are expected to do in any situation that affects the health safety and welfare of the people who use the service. The manager would discuss with the Trust to update the identified policies. The fire logbook was well maintained; the home maintenance book was in order. All fire system checks including the fire alarms, call bell systems, smoke detectors, emergency lighting, fire extinguishers were in date. Staff had received fire safety training on 10/09/07. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 23 Records examined showed that staff had attended regular fire drills in order to familiarize themselves with the action to be taken in the event of fire outbreak at the home. All staff records and other confidential information were noted stored in the lockable cabinet. Accidents were recorded on individual record sheets and there were follow-ups on some and discussion at the team meeting on how to prevent the accidents from happening again. Whilst there were guidelines in place on how to hoist an individual at the home, the home must ensure that the Occupational therapist (OT) is contacted to review the guidelines following a recent accident in order to ensure safety of the individual. The manager confirmed that contact had been made and an appointment had been booked for the OT to visit. Health and safety in relation to protection of the individuals living at the home were noted satisfactory. 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 15 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP38 Regulation 13(4)(c) Requirement Review risk assessments following high level of accidents to three individuals. Ensure that staff receive training on challenging behaviour. Ensure that the procedure for lifting a person is reviewed to ensure safety of the individual. Provide care plan on how to manage an individual’s challenging behaviour. Timescale for action 31/10/07 2 3 4 OP30 OP8 OP7 18 13 15 31/12/07 11/10/07 11/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.bristol@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 16 Cleeve Hill DS0000003385.V345143.R01.S.doc Version 5.2 Page 27 - 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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