Inspection on 09/05/05 for 16 Cleeve Hill

This inspection was carried out on 9th May 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 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 11/09/07

16 Cleeve Hill 23/10/06

16 Cleeve Hill 25/10/05

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 9 - 12 th th Announced May 2005 09:30 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 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 D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 16 Cleeve Hill Address Downend South Glos BS16 6HN 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) 0117 957 0839 0117 970 9301 Aspect & Milestones Trust Ms Jane Mary Ireland Care Home for Older People 5 Category(ies) of LD(E) Learning dis - over 65 registration, with number LD Learning disability of places 5 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 5 persons aged 18 years and over. May include persons aged 65 years and over. Date of last inspection 19-Oct-2004 Unannounced 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 communty facilities. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place for eleven hours and was undertaken to review the requirements made at the last inspection which took place on the 19th October 2004, 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. 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 days of inspection was friendly, staff were helpful and informative and were seen interacting with residents. All challenging behaviours noted on the days were dealt with sensitively and professionally. What the service does well: A 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 a Service Users’ Guide with information about the home; aims and objectives, management and staff to enable the prospective service user 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. 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 service users in a relaxed atmosphere and not hurried. Service users 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 the service users. Aids and equipment are provided to assist staff with meeting the needs of the service users. The home has an effective communication system that enables staff and supporting services to deal with the challenging needs of service users both within and outside the home. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 6 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. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 The home has a detailed, well planned and comprehensive admission process to enable any prospective service user 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 complaints procedure. All service users’ records viewed contained a statement of terms and conditions, detailing occupancy, period of notice, overall care and services covered and fees to be paid. The manager and service user representative or witness signs this document. There have been no new admissions to the home since the last inspection. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The home offers care and support throughout service users’ lives and towards the end of their life however, it has failed to protect service users from potential medicine administration malpractices. EVIDENCE: Service users living at 16 Cleeve Hill have been at the home for eight years since the home opened. All five service users’ care files were viewed and contained comprehensive and detailed information, which was 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 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. This information will provide staff with the knowledge required to meet service users’ needs. Two service user’s files viewed contained details of their complex needs and how these needs are being managed. One of the service user’s files showed evidence of visits from the district nurses to administer injection when the registered manager was not available. Another service user was provided with 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 10 specialist equipment to assist with meeting her needs. All the care files were regularly reviewed and annually. The care files 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 of a service user with epilepsy and depression. One service user interviewed stated that she was happy at Cleeve Hill, the service user stated ‘staff help me go to bed, staff give me respect, I can dress myself but sometimes staff help me’. Staff were noted assisting service users in a respectful and dignified manner. One of the service user’s files seen had evidence of social services recordings, on the review the relative stated that he/she was happy with the home and the care provided for his/her relative. The review notes also stated how the service user expresses happiness or low mood. 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 spoken with demonstrated knowledge and understanding of individual service users’ needs, including support for emotional needs. Three relatives comment cards received before the inspection confirmed that they were satisfied with the care and services received at the home. One comment card stated ‘ I am pleased to have the chance to pass my opinion with reference to the level of care provided at Cleeve Hill. We as a family are very impressed by the level of care delivered by Jane and her staff and can only praise them 100 ’. Another comment card stated ‘ This is a well run home, everyone is cheerful.’ The home has a medication policy, the manager stated that 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. It was noted while reviewing medication stored at the home that the home had two stocks of ‘when required’ analgesia for a service user dated March 2003. Both boxes had tablets dispensed from them but there was no evidence or recording on the present Medication Administration Record Sheet (MARS) of when it was dispensed. The manager stated that the service user only took the medication very occasionally. It was also noted that some discontinued medication dated 2004 had not been returned to the pharmacy. An immediate requirement was made for the returns and a small stock of the analgesia requested from the GP for the service user. This requirement was met before the completion of the inspection. The MARS were computer generated and all given medication was duly signed. Staff files examined showed no evidence of Basic Medication Administration training (except the Registered Manager who is a trained nurse). The manager explained that all the support workers working at the home were trained on medication administration by herself when the home was opened in 1997 and no further training had been given to staff since then. A requirement was made for the home to provide the staff at Cleeve Hill with an update on Basic 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 11 Medication Administration to ensure that service users are protected from medication administration malpractices. Staff spoken with demonstrated knowledge of the importance of keeping all information about service users confidential. Staff also demonstrated knowledge and understanding of how to support service users when terminally ill and at the time of death. The home has Death and Dying policy. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The home provides meaningful activities to service users, enables them to maintain contact with families and friends and ensures that choice is provided in respect of meals and meal times. EVIDENCE: All the care files reviewed contained summary of weekly activities. The manager stated that four service users attend activity sessions provided by Brandon Trust. One service user attends daycentre at Blackhorse RAC, Mangotsfield five days a week. These were recorded in the care files also in the individual service user daily diaries. Service users are supported to participate in the activities of their choice, one service user was seen being supported by a staff member to walk round the garden on the day of inspection and later sat out in the garden doing some paintings. Another service user was noted doing puzzles. Another service user was relaxing in the lounge threading beads. Two service users were taken out to the pub in the minibus for lunch on different days. One service user stated that she was picked up by her brother to visit mum when she was in hospital, and to visit mum at her brother’s house. Same service user stated that staff take her out for shopping to buy colouring books. The manager stated that the service user is worried about the impending closure of Blackhorse day centre but that extra money will be provided by social services when Blackhorse closes down. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 13 The manager stated that the service user cleans her room and changes the bed linen with staff support. One service user stated ‘I like laying the tables and putting the clothes on the line’. The home has a mini bus, which was purchased to assist service users with accessing the community. There was evidence of entry in the care file of one service user being supported to attend Almondsbury garden centre, Thornbury for lunch and Sainsbury’s for a walk about and lunch at the restaurant. It was recorded that the service user enjoyed those outings. Risk assessments were in place for all activities undertaken by individual service users. There was evidence of visits from service users’ family and friends. Service users are supported to make a choice of meals. The manager stated that there is no set menu but service users 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. Staff use their experience and knowledge of service users to make choices and assist service users with communication problems. Service users were seen being supported to have their meals at lunchtime, the meal was relaxed and service users were consulted for choices. Service users who are unable to feed themselves were supported and fed in a respectful, sensitive and dignified manner. One service user spoken with said that she enjoyed the meal. One service user had a specifically planned menu due to her medical condition. The kitchen was found to be clean; the fridge and freezer temperatures were regularly recorded. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Service users 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. There was a copy of complaints procedure in each service users care file. This was produced in a picture format which is relevant to the service users living at Cleeve Hill, however, this document did not have the Commission for Social Care information to enable service users and or their representatives to complain if they were not satisfied with the outcome of a complaint. A requirement was made to ensure that this information is included in the complaint procedure issued to service users. 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 service users. There were no recorded complains at the home. Staff spoken with stated that they had attended abuse training and there was evidence of this in the staff records viewed. Staff records viewed contained evidence of Criminal Record Bureau disclosure. The home has policies on Abuse of Vulnerable Adults, Whistle Blowing. The latter is to enable staff to report bad practices without fear of reprisal. One service user spoken with said that she felt safe at the home. There was documentary evidence that individual rights have been explained to the service users and where service users are unable to make choices or decisions, it was explained how they would be supported to make choices. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 15 Six of nine staff records viewed contained one reference before commencement of employment a requirement was made for the manager to ensure that two satisfactory references are obtained for the identified staff working at the home to protect service users. A letter was received on 1 June 2005 from the Personnel Officer from Aspects and Milestones Trust explaining the reason why the identified staff members had one reference each in their records and planned action to rectify the situation. This explanation has been accepted by the Commission. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23, 24,25,26 The home has a safe, clean, well-maintained environment, comfortable bedrooms and specialist equipment suitable for service users needs. 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 kept safe, tidy and attractive and accessible to service users. One service user was seen sitting on the garden chair and enjoying her activity. Other service users were found to be comfortable in a well-furnished homely environment. The manager stated that windows in bedrooms 1 and 2 and the front door are to be changed to double glazed ones to provide more warmth and security, also to prevent condensation. 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. One service user spoken with stated that she liked 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 17 her room. Another service user had the trophy she won at a ‘Talent contest’ displayed in her room. All the corridors had hand rails fitted on both sides to assist with service user’s mobility. The toilets and bathrooms had grab rails, manual handling equipment, hoists, and specialist high low bath to assist staff with meeting service user’s needs. The lounge and the dining area are combined but were individually decorated and furnished. The laundry was found to be clean, had good flooring, adequate ventilation and was accessible to service users who may be supported by staff to do their own laundry. A risk assessment was in place at the kitchen and laundry. A generic risk assessment needs to be undertaken in areas such as the bedrooms and the lounge and other areas that service users have access to, to ensure that the service users are adequately protected from hazards. The home had Control of Substances Hazardous to Health (COSHH) and Infection Control policy. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 The home ensures that there are adequate staff numbers of skill mix and competency along with training to protect service users. EVIDENCE: On the first day of inspection, there were three staff on duty, to include one Registered Nurse, for four service users with learning difficulties. One service user was attending the day centre until about 1600hours. On the second day of inspection. There were four staff on duty to include one Registered Nurse for four service users. The registered manager stated that bank staff are used to cover holidays and sickness but that agency staff are rarely used, this is to ensure continuity of care is maintained for service users. Reviewing of staff records showed that staff have attended various training to include manual handling, Protection of Vulnerable Adults, first aid, promoting independence and fire safety. The registered manager, deputy manager and senior support worker have achieved an NVQ at level four. The manager stated that three home support workers have completed NVQ level 3, one home support workers have almost completed NVQ level 3, and one home support workers have recently commenced an NVQ level 3. One home support worker had completed organisational competency. 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 service users and their roles in the home. There was good interaction between the staff and the service users, which demonstrated that there is a positive relationship between the staff and the service users. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 19 Aspects and Milestones have a recruitment policy, which was seen, at the home on the day of inspection. However staff records viewed lacked vital documentation in respect of the persons working at the home in order to protect service users. Specifically, out of the nine staff records viewed, six had only one reference before commencement of employment. Requirement was made for the registered manager to ensure that two satisfactory references are obtained in respect of identified staff. (Please see standard 18). One service user spoken with said that she felt safe at the home. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36 37,38 The home benefits from good leadership, and management, however, its practices do not fully protect the health and safety of service users. EVIDENCE: 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 listens, the other staff member also stated that ‘ Manager does not sweep things under the carpet’. Another staff member stated that ‘manager is good’. One service user stated that Manager is ‘all right’ Three relatives comments cards received before the inspection contained evidence of satisfaction with the care to service users. One comment card stated ‘ this is a well run happy home everyone cheerful’. 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 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 21 at the home showed that staff receive supervision regularly and are supported to perform their duties effectively. The home has different ways of monitoring its quality of service. This includes, Regulation 26 monthly visits, regular review of care plans, regular contact with service user relatives and friends. A monthly monitoring form has also been developed to include all aspects of the services provided and health and safety issues. There was also evidence of a yearly monitoring form, which also covers all services. This is to be completed by the registered manager to ensure that all issues identified are dealt with promptly. However, the home is required to develop a more comprehensive quality assurance system that will capture the views of other professionals, service users, representatives, families and friends. Service users monies held at the home tallied with the records seen. All service users had an up to date inventory of their belongings at the home. 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 included, Death and Dying, Abuse and Medication. 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. Staff had received fire lectures on 16/11/04, 6/1/05, 23/3/05, and another planned one on 16/05/05. Records examined showed that staff had not attended regular fire drills. The manager is required to ensure that all staff attend fire drills in order to familiarize themselves with the action to be taken in the event of fire outbreak at the home. There was evidence of food safety audit by the Environmental services and action had been taken on the recommendation given. There was no evidence of hot water temperature checks to eliminate the risk of legionnella hazard, however the facilities manager for Aspects and Milestones met on the day of inspection stated that there is low risk of legionnella because 16 Cleeve Hill is installed with a combination boiler which does not store hot water. The manager is required to ensure that hot water temperature of all the taps that are not valve controlled are recorded to prevent scalding. Service user files were noted stored in an unlocked cabinet, this was discussed with the manager and the files were removed and stored in a lockable cupboard on the second day of inspection. All staff and other confidential information were noted stored in the lockable cabinet. Accidents were recorded on individual record sheets however, there was no follow up on some of the sheets of how the injuries sustained were satisfactorily resolved. The home needs to follow up all accidents to ensure that service users are adequately protected. 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 3 3 x 3 3 3 2 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 23 yes 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 30 Regulation 18 Requirement Ensure that staff are trained on infection control, COSHH and an up date on Basic Administration of medication Return unwanted medication to the pharmarcy. Ensure complaints procedure includes the name, address and telephone number of Commission for Social Care Inspection Obtain two references for all identified staff working at the home. Keep service users records securely locked at the home. Record hot water temperatures on all taps that are not valve controlled. Ensure all staff attend fire drils regularly. Undertake risk assessment on all areas that service users have access to. develop a comprehensive system of monitoring the quality of services provided at the home. Timescale for action .12/6/05 2. 3. 9 16 13 22 9/5/05 .12/6/05 4. 5. 6. 7. 8. 9. 29 37 38 38 38 33 19 17 13 23 13 24 26/05/05 12/06/05 12/06/05 12/6/05 12/6/05 12/8/05 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 24 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 Good Practice Recommendations 16 Cleeve Hill D56_D05 S3385_16Cleeve Hill_V217125_9&100505_Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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