Inspection on 23/10/06 for 16 Cleeve Hill

This inspection was carried out on 23rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

16 Cleeve Hill 11/09/07

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 23rd October 2006 09:30 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.V315933.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.V315933.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 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.V315933.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 25th October 2005 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.V315933.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 took place over seven hours and was undertaken to review the requirements made at the last inspection, which took place on the 25th October 2005. Furthermore, the visit was undertaken to review the care practice to ensure that it is in line with the legislation and to ensure that best practice is followed at the home. It was pleasing to note that the home had made considerable effort to ensure that all but one of the requirements made at the last inspection were met. A tour of the building was undertaken and a number of records were reviewed. One resident and two staff members were spoken with on the day. 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. All challenging behaviours noted on the day were dealt with sensitively and professionally. An updated Statement of Purpose, which has the information on the ranges of needs that the home intended to meet, the admission criteria and information about dealing with complaints was in place at the home. The home has an updated Service Users’ Guide with information about the home; aims and objectives, management and staff to enable prospective residents and their relatives/ representatives to make an informed choice of moving into the home. The home has a statement of terms and conditions to include, occupancy, period of notice and fees to be paid. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 6 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. Service users are supported to participate in activities based on their individual capacities. Good and nutritious meals are provided for residents in a relaxed atmosphere and not hurried. Residents who are not able to feed themselves are fed in a sensitive and dignified manner. Relevant training courses are provided for staff to enable them to meet the complex needs of present individuals. Aids and equipment are provided to assist staff with meeting the needs of the residents. The home has an effective communication system that enables staff and supporting services to deal with the challenging needs of the residents both within and outside the home. The home provides good quality service for people with multiple needs and high level of emotional support. The manager and the staff team are a competent group who have acquired skills and knowledge and work very hard to ensure that the individuals living at the home are treated, as people not people with disabilities. Also the skills knowledge and experience acquired will enable the staff to support the individuals living at the home to live as a fulfilling life as possible. What has improved since the last inspection? The furniture in the lounge had been re-arrange to create more space for easy movement of the residents and staff and also to minimise the risk of falls. Generic risk assessments have been undertaken to include the lounge and other areas that the residents have access to in line with the requirement made at the last inspection. Control of Substances Hazardous to Health folder had been reviewed to ensure that residents and staff are adequately protected. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 7 To ensure that prospective residents and their relatives receive accurate information, the Statement of Purpose and Service Users Guide have been updated. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 16 Cleeve Hill DS0000003385.V315933.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.V315933.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): Quality in this outcome area is good. 1,2,3,4,5. This judgement has been made using available evidence including a visit to this service. The home has a detailed, well- planed and comprehensive admission process to enable any prospective resident to make an informed choice of moving into the home with the assurance that their needs would be met. EVIDENCE: The home has a Statement of Purpose and Service Users’ Guide developed by Aspects and Milestones Trust which has detailed information about the home, it’s aims and objectives, management details, the care team and training, what people can expect, quality of service, specialist care and the complaints procedure. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 10 The resident’s record viewed contained a statement of Terms and Conditions, detailing occupancy, period of notice, overall care and services covered and fees to be paid. These documents were recently updated to ensure that prospective residents and their relatives/ representatives receive accurate information about the home before making a decision to move in. The manager and residents’ representative or witness signs this document. There have been no new admissions to the home since the last inspection. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. 7,8,9,10, 11 This judgement has been made using available evidence including a visit to this service. The home offers care and support to residents throughout their lives and towards the end, it also protects the residents by reviewing their health needs and there is appropriate drug administration. EVIDENCE: Residents living at 16 Cleeve Hill have been at the home for nine years since the home opened. One resident’s care file viewed contained comprehensive and detailed information, which was person centred and holistically focused. The information recorded was to assist and support staff with meeting the needs of the resident in areas of personal, emotional, social and physical care based on the resident’s individual circumstance. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 12 Other information noted in the care files included, personal profile, support for daily living, ‘choices I can make, places I like to go,’ personal statement, other likes and dislikes, annual medical and social services reviews. The care file was regularly reviewed and annually. The care file also had evidence of visits from other health professionals to include General Practitioner (GP) Dentists, and opticians. One resident spoken with stated that she liked living at Cleeve Hill; the individual stated they get up and go to bed when they like and that staff respected them. Staff were noted assisting residents in a respectful and dignified manner. Each service user had handover notes completed by staff on each shift and individual diaries for all daily activities. There was evidence of risk assessments in place in relation to bathing, washing, mobility, personal hygiene and using a specialist chair. Staff met on duty and spoken with demonstrated knowledge and understanding of individual residents’ needs, including support for emotional needs. Five relatives, one General Practitioner and one health professional comment cards received before the inspection confirmed that they were satisfied with the care and services provided at the home. One relatives comment card stated ‘ I am very happy with the care given to my sister. I believe it is over and above what could be expected”. Another comment card stated, “ The level of care delivered by the staff at 16 Cleeve Hill is wonderful. My relative is very happy there and we have excellent communication with all the staff there”. The home has a medication policy, repeat prescriptions are completed and sent to the surgery on a monthly basis and the local pharmacist supplies the drugs after collecting the signed scripts from the surgery. The Medication Administration Record Sheets (MARS) were computer generated and all given medication was duly signed. Staff files examined showed evidence of Basic Medication Administration training. A Regulation 37 notification received by the Commission for Social Care Inspection in relation to omission of a resident’s medication on two consecutive 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 13 days was reviewed and discussed with the manager who explained that the support worker involved had left the home and that the risk to the residents had been eliminated. All staff working at the home have received medication competency training. Staff spoken with on the day of inspection demonstrated knowledge of the importance of keeping all information about the residents confidential. Staff also demonstrated knowledge and understanding of how to support residents when unwell due to terminally illness and at the time of death. The home has Death and Dying policy. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. 12,13,14,15 This judgement has been made using available evidence including a visit to this service. The home provides meaningful activities to residents, enables them to maintain contact with families and friends and ensures that choice is provided in respect of meals and meal times. EVIDENCE: The care file reviewed contained summary of weekly activities. The manager stated that four residents attend activity sessions provided by Brandon Trust. One individual attends daycentre at Blackhorse RAC, Mangotsfield five days a week. This was recorded in the care files also in the individual resident’s daily diary. This resident was attending the daycentre on the day of inspection. The manager stated that no new information has been heard about the possible closure of Blackhorse day centre and that the resident continues to enjoy her attendance there. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 15 Residents are supported to participate in the activities of their choice, two residents were noted relaxing in the lounge and enjoying the company of each other. One resident was taken out in the minibus for lunch and for a walk and afterwards to a pub for a cup of tea and a sandwich. The home has a mini bus, which was leased to assist residents with accessing the community. Other activities recorded in the files included games galore, Community education group, music group, focus group and chatterbox group. The manager stated that the residents were supported to enjoy a one-week holiday in Dartmouth last week. It was recorded that the residents enjoyed their holiday. 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 manager stated that relatives and friends visit the home quite often; one relative visits regularly on weekends. There was evidence of visits in the visitors’ book viewed. Residents are supported to make a choice of meals. The manager stated that there is no set menu however; residents who are able are encouraged to choose what they would like to eat on the day. These are recorded on the menu book on a daily basis. 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. 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. One resident with medical condition had a specifically planned menu suitable for that condition. 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.V315933.R01.S.doc Version 5.2 Page 16 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good, 16,17,18 This judgement has been made using available evidence including a visit to this service. Individuals living at the home are supported to complain and exercise their legal rights and are confident that the home is able to protect them from abuse. EVIDENCE: The home has a complaints policy and procedure from Aspects and Milestones and also a copy of complaints procedure in each resident’s care file. This was produced in a picture format, which is appropriate for the communication needs of the individuals living at Cleeve Hill. This document has the details of the Commission for Social Care information to enable residents and /or their representatives to complain if they were not satisfied with the outcome of a complaint investigated by the organisation. Staff spoken with demonstrated knowledge of how to enable service users to complain. One staff member stated, “When a particular individual behaviour changes, we know the person is unhappy and needs own space. We approach the person later to find out what is the problem”. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 18 There was evidence in the care file that the complaint procedure is explained to the residents based on their level of understanding using an appropriate form of communication. No recorded complains had been received at the Commission for Social Care Inspection since the last inspection. Staff spoken with stated that they had attended abuse training and was able to demonstrate knowledge of how to report any incident of abuse if it occurred. The staff member stated, “ I will report first to the manager any incident that is not appropriate for the resident.” Staff records viewed contained evidence of Criminal Record Bureau disclosure. The home has policies on Abuse of Vulnerable Adults and Whistle Blowing. The latter is to enable staff to report bad practices without fear of reprisal. One resident spoken with said that they felt safe at the home. There was documented evidence that individual rights have been explained to the residents and where residents are unable to make choices or decisions, it was explained how they would be supported to make choices. Two staff records viewed contained satisfactory employment documentation before commencement of employment to ensure that the residents were adequately protected. Recruitment is discussed fully under standard 36. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area good. 19, 20, 21,22, 25,26. 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 the residents. EVIDENCE: The home was found to be clean, tidy and free from offensive odours. The building was accessible, safe and well maintained. The home was also noted to be warm, well ventilated and well lit. The grounds to the rear of the home are tidy, attractive and accessible and provide safety to the residents and staff. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 20 Two residents were found sitting comfortably in a well-furnished homely environment. The corridor had hand rails fitted on both sides to assist with residents’ mobility. The toilets and bathrooms had grab rails, manual handling equipment, hoists, and specialist high low bath to assist staff with meeting residents’ needs. The lounge and the dining area are combined but were individually decorated and furnished. The lounge had been rearranged to provide mobile residents with more space to move around without risk of falls, also better access for staff to transport residents with wheelchairs and other specialist equipment. A generic risk assessment had been undertaken in areas such as the bedrooms and the lounge and other areas that residents have access to, to ensure that the residents are adequately protected from hazards. The laundry was found to be clean, good flooring, adequate ventilation and was accessible to residents who may be supported by staff to do their own laundry. A risk assessment was in place at the kitchen and laundry The home had Control of Substances Hazardous to Health (COSHH) and Infection Control policy. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. 27,28,29,30. 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 individuals living at the home. EVIDENCE: On the morning of the inspection, there were one permanent staff member working from 0800 -1530 and a bank staff working from 0800-1530 duty, for four residents with learning difficulties. The rota also showed that two staff members were due to come in at 14302200 and one waking night staff from 2145- 0815. One individual was attending the day centre until about 1600hours. The registered manager who was on a late shift came in late morning to assist with the inspection process and to relieve the staff members to concentrate on supporting the residents. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 22 The manager stated that one new staff has been appointed but has not commenced and that one staff member from another home would be commencing in November. The manager also stated that the same bank staff are used to cover holidays and sickness, this is to ensure continuity of care for the residents. To ensure that the residents’ needs are adequately met, there is an information folder for bank staff to provide them with information about the home and individual resident’s needs and how the needs are to be met. The manager spends time with any new bank staff member to ensure that they are aware of the residents’ needs whilst on duty. A review of staff records showed that staff have attended various training which includes manual handling, National Vocational Qualification (NVQ) updates Protection of Vulnerable Adults. Five staff members have First aid certificates, food hygiene, fire safety and five-day induction for new staff members. The registered manager stated that two Home Support Workers have been registered to undertake NVQ at level 2. Records evidenced that on 27/10/06 all staff working at the home have been booked to attend a talk on diabetes and nutrition at the Trust Head offices arranged by Diabetic Nurse. This talk will provide the staff with valuable information in relation to one individual with the condition at the home. Bank staff that are familiar with the home have been booked to cover for the day. Interviews with staff evidenced that staff have a range of skills and experience to enable them to meet service users’ needs. Staff also demonstrated understanding and knowledge of the residents and their roles in the home. There was good interaction between the staff and the residents, which demonstrated that there is a positive relationship between the staff and the residents. Aspects and Milestones have a recruitment policy, which was seen, at the home on the day of inspection. However, of two staff records viewed one contained only a CRB. This individual commenced employment at the home in March 2006. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 23 The manager stated that the individual’s file was at the Trust Head offices and had not been forwarded to the home. A requirement was made at the last inspection for the home to ensure that “records, including employment records are at all times available for inspection in the care home by any person authorised by the Commission for Social Care Inspection to enter and inspect the care home”. The manager contacted the Head Office and this file was brought to the home before the inspection was concluded. Satisfactory employment documentation in relation to this individual was noted in the file. The home is reminded that staff documentation must be at the home for inspection at all times. One resident spoken with said that they felt safe at the home. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is adequate. 31,33,35,36,37,38 This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership, and management; its practices do not fully protect the health and safety of residents. EVIDENCE: The manager was unavoidably absent in the morning on the day, however, two staff members met on the day showed satisfactory leadership qualities and 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 25 assisted professionally with the smooth running of the home and the inspection process before the arrival of the manager later on. Staff spoken with on the day of inspection made positive comments about the manager and the organisation. One staff member stated, “The manager is fair, professional and understanding. She is approachable and very supportive. I can go to her to ask of anything that I don’t understand and she will be happy to talk me through it. Staff work as a team. Everyone has been helpful since I have been here”. One individual spoken with stated that Manager is ‘good.’ Five relatives comments cards received before the inspection contained evidence of satisfaction with the care to service users. One comment card stated, “ Jane Ireland and all her staff are a team to be very proud of” The manager stated that she receives regular monthly supervision from her line manager and that she is well supported by the organisation to meet the challenges of her responsibilities. Evidence from the staff records at the home showed that staff receive supervision regularly and are supported to perform their duties effectively. Records showed that one staff was supervised on 2/8/06 and 25/09/06 and another staff on16/8/06 and 21/09/06. The home has different ways of monitoring its quality of service. This includes, Regulation 26 monthly visits, regular monthly review of care plans and other information in the care file to include supervision of the residents, risk assessments, diet and weight, menu and chequebooks. Questionnaires sent to relatives to seek their opinion in relation to care of the residents and other services provided at the home were seen on the day. Six responses from the relatives showed overall satisfaction in the all areas surveyed. The manager stated that relevant questionnaires are being developed for visitors, General Practitioners and Health professionals. Aspects and Milestone’s yearly audit overview covering, finance, health and safety Control Of Substances Hazardous to Health, pharmacy and food is shortly to commence. There are comprehensive updated policies and procedures provided by Aspects and Milestones at the home. Staff spoken with was able to demonstrate knowledge of where these were kept. Policies seen included, responding to racist incidents, Death and Dying, Protection of Vulnerable Adults from Abuse and Medication. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 26 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 lightings, fire extinguishers were in date. There were individual fire risk assessment for all the residents and fire safety training was provided for the new bank staff. Other health and safety records viewed including Gas and boiler service, hoist servicing, Portable Appliance Testing were also in date. Records examined showed that staff had attended regular fire drills. Evidence showed all staff attend fire drills on 25/05/06, 26/06/06, 29/06/06 in order to familiarize them with the action to be taken in the event of fire outbreak at the home. Accidents were recorded on individual record sheets and were followed up on all of the sheets to provide information on the outcome of the accident and how the injuries sustained (if any) were satisfactorily resolved. However, it was noted that there were high numbers of accidents to two residents. This was discussed with the manager and it was agreed that whilst the accidents were reviewed in terms of injury, it was necessary to review the risk assessment following each accident and ensure that action plan is in place to minimise or prevent further accidents. This was followed with a requirement to protect the residents. Review of the resident’ monies showed that accurate record is kept and the balances locked away tallied with the records seen. All other residents’ information were securely locked away. 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 16 Cleeve Hill DS0000003385.V315933.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13(4)(c) Requirement “The registered manager shall ensure that- unnecessary risks to the health and safety of service users are identified and so far as possible eliminated”. (Review risk assessments following high level of accidents to two individuals). Timescale for action 12/11/06 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.V315933.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 16 Cleeve Hill DS0000003385.V315933.R01.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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