Inspection on 03/04/07 for 185 Passage Road

This inspection was carried out on 3rd April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

185 Passage Road 17/02/09

185 Passage Road 31/12/07

185 Passage Road 10/04/06

185 Passage Road 15/09/05

185 Passage Road 21/04/05

185 Passage Road 13/09/04

185 Passage Road 27/04/04

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 HOME ADULTS 18-65 185 Passage Road Brentry Bristol BS10 7DJ Lead Inspector Jacqueline Sullivan Key Unannounced Inspection 3rd April 2007 09:30 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 185 Passage Road DS0000026543.V334285.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 185 Passage Road Address Brentry Bristol BS10 7DJ 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 9509586 0117 9699000 www.brandontrust.org The Brandon Trust Ms Jo-anne Elizabeth Dixon Care Home 7 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (3) 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate male persons only May accommodate persons aged 40 years and over May accommodate persons with a Learning Disability and additional Mental Disorder 10/04/06 Date of last inspection Brief Description of the Service: This home is registered to accommodate 7 male residents with a learning disability. The current resident group have a variety of complex needs whose ages range from 43-88 years. The Registered Providers for this home are the Brandon Trust. This single level home is situated on Passage Road and is close to local amenities. There are local bus stops providing easy access to the city centre and to Cribbs Causeway and its shopping facilities. The home blends easily into the local community and is in keeping with the neighbouring properties. The home is fully accessible to the current resident group providing ground floor accommodation. However a ramp is needed to ensure full access to the grounds for residents whose mobility has deteriorated. There is a large well-kept garden mainly laid to lawn with fruit trees. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second unannounced ‘Key’ inspection carried out for this home. The purpose of this visit was to review the requirements previously set and review care practice in the home. The inspection record was used to ensure all information received about the service was taken into consideration when carrying out the inspection. A pre-inspection questionnaire was sent to the home as was resident feedback questionnaires. Information gained from these has been used to inform this report. Questionnaires were also sent to relatives of the residents’ case tracked and to their General Practitioner. Four residents were case tracked and a number of records examined for one other. The inspector spoke to 2 residents and 3 staff members all of whom provided information for the compilation of this report. Documentation was examined relating to residents and to the general running of the home and health and safety issues. What the service does well: What has improved since the last inspection? 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 6 The resident’s health needs are better protected as appropriate referrals have been made to enable an assessment to take place for the provision of pressure relieving equipment. What they could do better: The resident’s needs are not being fully met as the personal information relating to residents has not been updated on admission and continues to remain incorrect. This is the third requirement and progress towards this requirement will be closely monitored. The residents are not receiving adequate information about the care they will receive as they do not have up to date contracts detailing the terms and conditions of their residency and what they can expect from the service. This is the second requirement and progress towards this requirement will be closely monitored. The residents would be better informed if a copy of the statement of purpose was updated and a copy sent to the Commission. The staff team would be better assured that they are working consistently if all staff received formal supervision at least 6 times a year and staff meetings were monthly The Commission would be in a better position to ensure that the service is working within its statement of purpose if they were informed in writing if there is a change in management. The residents would be better protected if contracts were signed by the residents and/or their representatives. The residents would be better assured that the staff team were meeting their needs if the issues raised at one residents meeting formed the agenda for the next. This would mean that every one would be clear what has taken place to resolve these issues between the meetings. The residents would be better assured that they live in a well-maintained environment if the water flow to the bath were fixed and the garden furniture were stained to retain the quality and appearance of the wood. 2nd recommendation The residents would be better protected if risk assessments are reviewed at least 3 monthly. 2nd recommendation 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 7 The residents would be better protected if protection training were added to the rolling programme of statutory training provided and that all staff attend a training session with Bristol City Council relating to ‘No Secrets’. The residents would be better assured that the staff team were meeting their needs if the ‘quick view’ sheet to record all activities undertaken with residents was completed more fully. 2nd recommendation The residents would be better assured that the staff team were meeting their needs if there was clear evidence why the a riser/recliner chair was not purchased for one resident. 2nd recommendation The resident’s health needs would be better met if old medication was returned to the Pharmacy and medication is not stock piled. 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. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Contracts are still not being consistently updated from one home to another. This means that residents are unaware of the terms and conditions of their stay at 185 Passage Road. The statement of purpose cannot easily be located. EVIDENCE: Documents relating to the last person who moved into the home were examined. As noted at the last inspection, the address for this resident was recorded as his last placement and his contract referred to his old home. At this inspection it was noted that all of his personal information still needs updating to relate to passage road. On file there was an agreement, which noted the room to be occupied but the document did not note at which home or the fees to be paid. Four other files had agreements in this condition. A requirement has been made that the staff team ensure all personal information relating to residents is updated on admission and reviewed as necessary. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 10 Four contracts were seen and all four were not signed by the resident or their representative. Therefore there was no evidence that these people had read and agreed to the contract. A member of staff at the inspection could not find the statement of purpose and this staff member did not know what the statement of purpose was. Therefore, as there have been several changes of manager and a high staff turnover, a requirement has been made that the statement of purpose is updated and a copy sent to the Commission. Further, it is recommended that all staff be trained in the content and reason for a statement of purpose so that they understand how it relates to their job and that they can answer any questions that the residents or their representatives might ask. The service user guide was not examined at this inspection although was seen to include all necessary information as required by legislation at the last inspection. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from more frequent reviews of their risk assessments to ensure the risk identified and action taken to support remains current. Residents are able to make their own decisions relating to everyday life. EVIDENCE: There was little evidence that all the staff had received dementia training as the manager said that the majority were new staff that had only completed the induction. At the last inspection care plans were examined and it was noted that some were in urgent need of review. The planning for life folders were not all up to date and the Person Centred Planning sections were often blank. The folders contain templates that, if well recorded would benefit the residents in that a comprehensive collection of information would be available to offer support. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 12 Risk assessments seen did not consistently link to care plans. Residents confirmed through discussion with the Inspector and via the surveys. that they can make their own decisions and choices within their everyday lives. It is unclear as to how residents that are less able to communicate are involved in decision-making processes. This is particularly relevant in the residents meetings. It was clear from reading the minutes that some residents have very clear ideas and concerns and suggestions but once these were made at a meeting there was no evidence that they had been acted upon by the staff team. A recommendation has been made that the issues raised at one meeting form the agenda for the next so every is clear what has taken place to resolve these issues between the meetings. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the residents have the opportunity to have a variety of activities. The residents do not always have a choice of the food they eat. EVIDENCE: At the last inspection it was noted that a requirement for the improvement in activities for residents with little or no day care services had been met. A recommendation was then made that a quick view sheet be put in place to record all activities undertaken with residents. This would ensure an adequate review and inform staff at a glance if more or less input is needed. At this inspection it was noted that the sheet is in operation but there is no evidence that the residents attended these activities. Some residents had an activity most days but others had very few. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 14 Day care workers (choices for learning) were observed working with specific residents. It was evident that positive relationships had been formed and the residents enjoyed their sessions. There was a planned holiday to Blackpool, which a resident said he was looking forward to and a trip to the theatre. Two residents stated in the surveys that they would like to go out more at the weekends. This resident said that when they get a minibus it would be easier to go out. The manager said they have plans to get one soon. Another resident has an NVQ in cleaning and support services and maintains a cleaning job working for the Brandon Trust. There was good input from ‘choices for learning’ and sound information in place regarding likes and preferences. This person has also attended various college courses of his choice and has an array of different interests, which he is supported to pursue Whilst there are two residents in the home that smoke there is a policy in place to support this. This was confirmed by the deputy manager (now acting manager) and another staff member who said, “residents must be supervised when smoking and can only smoke in the designated area”. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support in a way that suits them and referrals are made to other healthcare professionals to ensure health care needs are met. Residents are protected by robust medication policies and procedures and PRN medication is administered appropriately. The residents are supported by the staff team but this could be improved to include more detailed key worker meetings. EVIDENCE: As noted at the last inspection medication administration record sheets were examined and found to be in order. One staff member was able to carry out a stock check of the ‘as and when’ (PRN) medication and it was noted that all balances were correct at the time of inspection. PRN medication was noted to be used appropriately and the appropriate reviews of medication had taken place with the consultant psychiatrist. One staff member was able to explain 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 16 when and the administration of PRN medication. This was seen to be in line with specific plans of care. Scrutiny of the medicals cabinets showed that one has a stockpile of medication and old medication to be returned to the Pharmacist. Key worker meetings are not in place. The majority of the residents communicate verbally and these meetings are useful for checking out resident’s views and are a means of bringing together al the information about a resident to share. Currently on file there is monthly recording this is a useful summary but doesn’t have the fine detail of a key worker session that will look in depth at every aspect of care as defined by the care plan. A recommendation has been made that these are in place. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 21 22 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good arrangements in place for making sure that individuals are able to make complaints however improvements could be made to evidence that the complaints was resolved to the residents satisfaction. The residents would be better protected if the staff team were trained in the implementation of the whistle blowing policy. EVIDENCE: Comprehensive policies and procedures were seen to be in place in relation to complaints. The complaints book showed that residents can and do make complaints and these are acted upon by the staff. The information in this book did not include information about whether the outcome was to the resident’s satisfaction. There was no evidence that staff have apart from the induction training a rolling programme of POVA training. A member of staff had no knowledge about “Whistle blowing”. A recommendation has been made about this issue Verbal and physical aggression displayed by residents was discussed with staff who were aware of the correct procedures to follow. Scenarios were discussed relating to abusive behaviours and staff were able to demonstrate that they knew what to do and who to report their concerns to. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 18 There were no concerns raised by the residents via discussion or though the surveys. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All areas of the home meet the needs of the current resident group and the installation of a ramp to the rear garden will further support mobility and independence. The standard of the office /sleeping in room needs to be improved so that the staff team have better working conditions in which to deliver a good service to the residents. The home is clean and tidy. EVIDENCE: At the last inspection it was noted that although the home is accessible to the current resident group it is strongly recommended that a ramp be installed for ease of access to the rear garden. This will meet the changing mobility needs of residents. The acting manager confirmed that the Brandon Trust has agreed 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 20 the installation of the ramp but they are still waiting. At this inspection it was noted the manager stated that the cost of the ramp was around twelve thousand pounds therefore they were looking to have a pathway. A recommendation has been made that this is sorted out quickly. A resident said he likes the garden and knew about the plans for a path, which he agreed with. The house although clean and tidy was a mixture of homely and institutional. All the doors were blue and the corridors looked bare and hospital like. The lounge was homely and the resident’s rooms were personalised. A resident said he liked his room and spent a lot of time on his karaoke machine. The bathrooms seen were clean but a resident said the pump wasn’t working and it was difficult to run a bath, which he found annoying. The manager said they knew about the problem and had various plumbers in to fix it. A recommendation has been made that this is resolved quickly. At the top of the house is the staff sleep in room, which doubles up as an office. The room is very small with only space for one chair so any visitors professional or relatives have to either use this chair or sit on the bed. The desk in the room is very small and the shelves are disorganised and crampt. Also in this room are all the medication cabinets. In this space are the staff belongings and some stored equipment. The staff said it is hot and stuffy in the summer and very cold in the winter. Some female staff choose not to sleep in this room as they have to lock themselves in as a male resident will try and gain entry to the room in the night. They choose to sleep in the lounge. This is unsatisfactory as it limits the resident’s movement around the house if at night their lounge is a staff bedroom. As an office it presented as disorganised and staff found it difficult to find documents requested for the inspection. As a sleeping- in room, the bed is too small for tall members of staff and there is nowhere for the staff to keep their private belongings. As a space for supervision it is limited as a residents room is opposite. A recommendation has been made that this space is changed, as it neither meets the needs of an office or a sleeping in room. It is not clear if the residents have the equipment they require as at the last inspection a requirement was made for a riser chair but it was not bought, as it was not needed. The Physiotherapist recommended its use at the time. The manager said it is not now needed. But there is not a risk assessment for its use is in place or an update of this assessment to clearly say why it is now not needed. There should be a clear line of evidence as to why specialist equipment recommended by a professional in health care is not in place. A recommendation has been made about this 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team has undergone many changes therefore the systems that ensure the residents receive a good service are not all in place. EVIDENCE: Recruitment practice was discussed with two staff members and each confirmed that they have had Criminal Record Bureau checks carried out prior to starting employment. Both confirmed two references were sought and the appropriate induction was taking place. Staffing records are kept at the Brandon Trust headquarters and are available for inspection. The acting manager confirmed that staffing levels were now appropriate to meet the needs of the residents. Staff confirmed they attended various training courses both statutory and resident related. However there was little evidence that the current staff team had completed much training since the last inspection. At the last inspection it was noted that records show that night staff have limited opportunities to attend training designed to meet the specific needs of 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 22 residents as they fit training in around their hours. It was recommended that when training is provided regular or bank staff fill in for the night shift. At this inspection it was noted that this still remains the case. There are no staff meetings so staff have no opportunity to meet as a group for information sharing about changes to the organisation, policies ect and to ensure they are working consistently with the residents. Scrutiny of the staffing records confirmed that the staff team also do not receive supervision at the required frequency. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have not benefited from a consistent management approach to the home. Therefore the new manager has a lot of work to do to ensure that the staff team are working together as a team to provide a consistent service for the residents. The health and safety of residents is promoted and there are adequate policies and procedures in place to assist staff members. EVIDENCE: There have been several changes of manager in about a year. A requirement has been made that the Commission is informed in writing about these changes. The current manager is starting to undergo the regulation process with a returned application for completion. This must be done promptly. The 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 24 manager has many years experience of managing a similar home. With several managers there has been different ideas and ways of working the Deputy said he now feels that he can work more consistently as there is a manager with whom he works well with. These changes have impacted upon the staff. The staff team is relatively new and it was clear that the staff are not clear about all the documentation that supports the service. Consideration should be given to introducing these into supervision sessions. A requirement has been made else where in the report in relation to additional staff training. The home’s certificate of insurance was displayed, as was the registration certificate. The home has many policies and procedures put in place by the Brandon Trust to safeguard residents and staff. Policies are adopted and adapted to suit the home. Unless identified throughout this report records were generally up to date, daily records were kept and records of a confidential nature were kept in a lockable facility. The Service Development Manager (SDM) carries out monthly ‘regulation 26’ visits to ensure the service is running smoothly and offer support. Copies of the reports are sent to the CSCI. 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 3 2 3 2 3 3 3 3 185 Passage Road DS0000026543.V334285.R01.S.doc Version 5.2 Page 26 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 2 Standard YA1 YA5 Regulation 4 Requirement Timescale for action 30/08/07 30/08/07 A copy of the updated The statement of purpose is sent to the Commission. 17(3)(a)3(3)(a- All personal information q) relating to residents must be updated on admission and reviewed as necessary. The residents’ register must be completed. 3rd requirement 5(1)(c) All residents must have a written setting out the terms and conditions of residency at the home 2nd requirement All staff must receive formal supervision at least 6 times a year. 3 YA5 30/08/07 5 YA36 18(2) 30/08/07 6 YA23 13(4)(b)(c) Follow the recommendations 30/08/07 of healthcare professionals to ensure any risk to the health and safety of residents is identified and where possible eliminated. The Commission is informed in writing if there is a change in management. DS0000026543.V334285.R01.S.doc 7 YA37 8 30/08/07 185 Passage Road Version 5.2 Page 27 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 2 3 4 Refer to Standard YA36 YA1 YA5 YA8 Good Practice Recommendations Staff meetings are monthly Staff receive training about the statement of purpose and the office is reorganised so it can be easily found. Contracts are signed by the residents and/or their representatives. Issues raised at one residents meeting from the agenda for the next so every is clear what has taken place to resolve these issues between the meetings. The water flow to the bath is fixed. Ensure that all residents have ease of access to the rear garden. The garden furniture is in need of wood staining to retain the quality and appearance of the wood. 2nd recommendation Ensure risk assessments are reviewed at least 3 monthly. 2nd recommendation Protection training to be added to the rolling programme of statutory training provided and that all staff attend a training session with Bristol City Council relating to ‘No Secrets’. Provide training relating to the needs of the resident group. Ensure all residents have access to dental services and record appropriately. The ‘quick view’ sheet recommended at the last inspection, sheet to record all activities undertaken with residents is completed more fully so as to inform staff at a glance if more or less input is needed. 2nd recommendation The office/sleeping in room is suitable for its purpose. There is clear evidence why the a riser/recliner chair was DS0000026543.V334285.R01.S.doc Version 5.2 Page 28 5 6 7 YA27 YA24 YA24 8 9 YA9 YA22 10. 11 12 YA32 YA19 YA14 13 14 YA24 YA19 185 Passage Road not purchased for one resident, identified at the last inspection, who prefers to remain in his bedroom and whose mobility has deteriorated as this was a recommendation of the occupational therapist. 2nd recommendation 15 16 17 18 YA39 YA20 YA18 YA35 Provide evidence that the issues raised by the residents are acted upon by the staff team. Old medication is returned to the Pharmacy and medication is not stock piled. Key worker sessions are in place. When training is provided regular or bank staff fill in for the night shift to enable night staff more opportunity to attend. 185 Passage Road DS0000026543.V334285.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 185 Passage Road DS0000026543.V334285.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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