Inspection on 23/06/08 for 19 Berryfield Road

This inspection was carried out on 23rd June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Berryfield Road 02/08/06

19 Berryfield Road 16/02/06

19 Berryfield Road 20/10/05

19 Berryfield Road 17/01/05

19 Berryfield Road 25/06/04

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 07/11/2008.

CARE HOME ADULTS 18-65 19 Berryfield Road 19 Berryfield Road Bradford on Avon Wiltshire BA15 1SU Lead Inspector Elaine Barber Unannounced Inspection 23 June and 23rd July 2008 10:50 rd 19 Berryfield Road DS0000028389.V364467.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 19 Berryfield Road DS0000028389.V364467.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. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Berryfield Road Address 19 Berryfield Road Bradford on Avon Wiltshire BA15 1SU 01225 868058 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) Ordinary Life Project Association Ms Joanne Burrows Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: The home is run by the Ordinary Life Project Association (OLPA). 19 Berryfield Road is a domestic style, semi-detached property in a residential area of Bradford on Avon. It is next door to another OLPA care home, which is at no. 17. There are some local facilities and a nearby bus route. The town centre offers a wider range of shops and amenities. The home has its own people carrier for trips out. Each person, who lives in the home, has their own room on the first floor. There is a communal lounge with a dining area. There is a large garden at the rear of the property. The people receive support and personal care from the home’s manager and a permanent staff team. At least one member of staff is on duty when people are in the home. People are supported with a range of community activities. Fees range from £750 per week. Inspection reports are available in the home and from the CSCI website at: www.csci.org.uk. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We visited 19, Berryfield Road on 23rd June 2008. The manager was present during the inspection. We made another visit to the area office on 23rd July 2008 to look at the recruitment records. The manager sent us an Annual Quality Assurance Assessment (known as the AQAA). This was their own assessment of how they are performing. It also gave us some numerical information about the service. We met with four people who lived in the home. We met with the staff member on duty during the day, to obtain their views about the service. We also observed interactions between the staff members and the people who lived in the home. As part of the inspection process, we sent surveys to the care home for distribution to the people who lived there and their relatives. We received surveys back from one relative, two staff and a healthcare professional. We looked at various records and documents during the visit. These included care plans, risk assessments, health care and arrangements for managing medication, activities, complaints, staff recruitment and training. We looked at systems such as health and safety and quality assurance and also the accommodation. During the visit we assessed all key standards. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people who live in the home. What the service does well: There was statement of purpose although this needed updating. There was also a service user guide in words and pictures. These were given to people before they moved into the home. This meant that people had most of the information they needed about the service to know what to expect from the service. People’s needs were assessed before they moved into the home so that their needs could be met. People could visit the home before they moved in so that they could decide whether it was the right place for them. Each person a license agreement and a contract with social services and the home. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 6 Each person had a care plan and a person centred plan so that their needs, wishes and goals could be met and they felt well cared for. People made decisions about their lives and were supported to take risks as part of an independent lifestyle. People had activities that they enjoyed, including attending day services and college. They had opportunities to use community facilities such as the supermarkets, shops, cafés and garden centres. They kept in contact with their family and friends as they chose. They were involved in the routines and decision making in their home and they had a healthy diet and enjoyed their meals. People received personal care and support in ways they preferred to meet their needs. Each person was registered with a GP and saw other health care professionals as they needed. People’s physical and emotional health care needs were met. Staff supported people with their medication and people were protected by the systems for managing medication. People’s complaints were taken seriously and acted upon. There was a complaints procedure and people were given information about how to complain. There was also a protection from abuse policy and information about the local procedures. Staff had received training about prevention from abuse. People were protected from abuse, neglect and self harm. The home was an ordinary semi-detached house in keeping with other houses in the road. There was a large lounge and dining room and each person had their own bedroom which was decorated and furnished according to their personal taste and wishes. The home was clean and tidy when we visited. People lived in a homely, comfortable, clean and safe environment suited to their needs. People were supported by staff who were qualified and trained to meet their needs. There were sufficient staff on duty to meet people’s needs. The manager was appropriately qualified and experienced to manage the home. The necessary health and safety measures were in place. As a result people benefited from a well run home, where their safety and welfare were promoted. There was a quality assurance process. People were contributing to a review of quality in the home so that the home was run in their best interests. What has improved since the last inspection? We recommended at the last inspection that the manager should have training about prevention from abuse. The manager had this training the previous September. This would help to give the manager a better understanding of how people could be protected. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 7 A new carpet had been laid in the lounge and the hall, stairs and landing had been redecorated. People had been involved in choosing the décor and the new carpet and benefited from these improvements to their home. The quality assurance process had been developed further. Questionnaires were sent to people and their views were gathered. A development plan, based on their views and ideas about how the home could improve, had been written and was being acted upon. 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. 19 Berryfield Road DS0000028389.V364467.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 19 Berryfield Road DS0000028389.V364467.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, 2, 4, 5 Quality in this outcome area is good. People had most of the information they needed about the service to know what to expect from the service. People’s needs were assessed before they moved into the home so that their needs could be met. People could visit the home so that they could decide whether it was the right place for them. Each person a license agreement and most people had a contract with social services and the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the Statement of Purpose. This contained some out of date information and needed to be updated. We also looked at the service user guide, which was in words and pictures. The manager told us in the AQAA that they gave copies of the service user guide and statement of purpose to people who were thinking about moving into the home. One relative said in their survey that they and their relative had enough information about the home to make decisions. There was information in the statement of purpose about the admissions procedure. The manager told us in the AQAA that prospective new tenants 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 10 had visits to the home before they move in. One person had moved into the home since the last inspection. When we looked at their file we read that the admissions procedure had been followed. They made several visits to the home to meet the staff and other tenants before they decided to move in. Their relatives also visited. The person had a tea visit and a dinner time visit and also went shopping with other people who lived in the house. They moved their things in with the support of the family. The person had a copy of their care management assessment in their file. The other three people had moved into the home before the last inspection and their needs had been assessed before they moved into the home. Each person had a copy of their license agreement and a copy of their contract with the home and the local authority that paid for their care. 19 Berryfield Road DS0000028389.V364467.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, 9 Quality in this outcome area is good. Each person had a care plan and a person centred plan so that their needs, wishes and goals could be met and they felt well cared for. People made decisions about their lives and were supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the files of three people. Each person had a care plan, which described the support that they needed with daily living. One person’s care plan was in words and pictures. Each person also had a person centred plan, which described the support that they needed with their life plan and long term goals. The care plans were reviewed monthly and there was a checklist to record this. Each month identified a section of the care plan that had been reviewed. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 12 There were sections described including; communication needs, night and day routines, eating and drinking, and leisure activities. There were signposts within the care plan to other documents that supported the person with a particular need. Each care plan contained an anti-discrimination and an anti– oppressive action plan. We saw the daily diary, keyworker meeting notes and tenant meeting notes which showed how people were involved in decision making and offered choices about activities inside and outside of the home. These notes were clear and objective, showing how people had been included and taken part in choices on offer. When we talked to people they told us about decisions they had made, for example, about the décor of their rooms and shared areas of the home, the choice of the carpet and when to go out. They also told us about how they made decisions about the routines of the home for example what meals to prepare and what food to buy. We saw one person going out to the shop to buy their newspaper. When we read the records we saw that people chose their activities. They also made decisions about their personal goals and these were recorded in the person centred plans. Each person had a series of risk assessments. These were very individual according to each person’s activities and daily routines. They included the action needed to reduce risks to the person. Some of them included the benefits to the person of taking the risk. The manager told us that each person is given a copy of their risk assessments and the staff talk to each person about them. 19 Berryfield Road DS0000028389.V364467.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): 12, 13, 15, 16, 17 Quality in this outcome area is good. People had activities that they enjoyed. They had opportunities to use community facilities. They kept in contact with their family and friends as they chose. They were involved in the routines and decision making in their home and they had a healthy diet and enjoyed their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People told us about their activities and there was a record in each person’s file about their weekly activities. On week days people went to various day time activities such as a day centre, college courses, a club and voluntary work. One person had had a job and was looking for another. When we visited there was a busy atmosphere to the house as people left for their activities and returned at different times throughout the day. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 14 People also talked about their leisure activities and there were records of these. People went to a social club on Wednesday evenings and they went shopping for clothes and for food. They also visited garden centres, went to cafes, had picnics in the park and had trips out, for example to Trowbridge. People told us that they had been on holiday to a caravan, owned by the organisation, in Weymouth. When we talked to people they told us that they were involved in the routines of the home. The records also showed that they were involved in the general household chores such as laying the table, clearing away, loading the dishwasher and vacuuming. People cleaned their own rooms and did their laundry with varying levels of staff support. Some people were involved in gardening and one person particularly enjoyed gardening. People said that they kept in contact with their families and friends. There were records in the personal notes when people had seen family or friends. People were also supported to maintain personal relationships if they chose. People told us that they were involved in food shopping and choosing their meals. They said that staff asked them every Saturday what they wanted to eat, then planned the menu for the week. People also said that they were involved in cooking. The menus and food records showed that people were offered choices and had a varied diet. People said that they enjoyed the food. 19 Berryfield Road DS0000028389.V364467.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, 19, 20 Quality in this outcome area is good. People received personal care and support in ways they preferred to meet their needs. People’s physical and emotional health care needs were met. People were protected by the systems for managing medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that the care plans described how people liked to be supported. We saw in the files that there was a policy and that each person had a record of whether they were agreeable to support from a member of staff of the opposite gender. There were clear guidelines for staff to follow when supporting people with managing aspects of their behaviour. There was also information about specific conditions that people may have for staff to read and understand. There were risk assessments and records of the support that had been provided with some behaviours. Records were kept of appointments with health care professionals. These showed that people had appointments with their GP’s, a psychologist, a psychiatrist, the dentist, optician, podiatrist, community nurse, occupational 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 16 therapist and physiotherapist. A health care professional told us in their survey that people’s health care needs were met by the home. They also said that staff seek advice about how to manage and improve people’s health care needs, and act upon the advice. There was a record in each person’s file of any medication that they took and of any reviews by the GP or psychiatrist. There was also a record of each person’s capacity to consent to treatment. The manager said that staff explained what medicines were for and people understood the need for them. A record was kept of all medication ordered, received into the home, administered to people and returned to the pharmacy. Medication was stored in a locked cupboard. There were no controlled drugs. We made a recommendation at the last inspection that greater use is made of outside trainers for training staff about medication. The manager said that staff had training about medication annually and this was linked to National Vocational Qualifications (NVQ). They told us that training was provided internally but there was a video from an external training provider to support this. The manager said that the NVQ part of the training was assessed externally so that they did not think it was necessary to provide external training. 19 Berryfield Road DS0000028389.V364467.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): 22, 23 Quality in this outcome area is good. People’s complaints were taken seriously and acted upon. People were protected from abuse, neglect and self harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw information about how to make a complaint in the statement of purpose and service user guide. We also saw that there was a complaints procedure with words and pictures. Each person had a stamped addressed postcard to the CSCI in their bedrooms, for them to use if they needed to. There had been no complaints since the last inspection. There was guidance in the home about adult protection, which was linked to the Wiltshire and Swindon ‘No Secrets guidance. We saw a booklet on the notice board. The training records showed that all staff had received training about protection from abuse and one relief member of staff needed an update. At the last inspection we recommended that the manager attended an external adult protection training course. They had received training in September 2007. There had been no referrals to the adult protection team. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 18 There were additional policies and procedures on whistle blowing, bullying and harassment and these had been reviewed. There were also separate descriptions of how people received support with managing their money. People had signed a form to confirm that they wanted staff to help them with their money. Records were kept of financial transactions when staff were helping people with their money. People signed the records when they had been given money. Receipts were kept. 19 Berryfield Road DS0000028389.V364467.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 good. People lived in a homely, comfortable, clean and safe environment suited to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 19 Berryfield Road is in a quiet residential area not far from the shopping area of Bradford on Avon. One person showed us round the home and showed us their room. On the ground floor, there was a large sitting room, which led into a dining room, a separate kitchen and a cloakroom. A new carpet had been laid in the lounge since the last inspection and the hall stairs and landing had been redecorated. One person told us that people had been involved in choosing the décor and the new carpet. They said that there was a plan to lay the same carpet in the hall, stairs and landing. There were four bedrooms on the first floor a 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 20 bathroom and a separate toilet. Each person had their own bedroom and these were decorated and furnished to reflect their taste. The utility room was in the garage, which had a coating on the floor to make it water resistant. In this room there were a washing machine and tumble drier, which provided sufficient laundry facilities. One person said that they did their own laundry and ironing and other people did their laundry with support. There was a large garden to the rear of the home, which a slope and handrails and a patio area with table and chairs. The garden was well stocked with different flowers and one of the people liked to work in the garden. In the AQAA the manager told us that there had been improvements to the front and back gardens since the last inspection. The home was very clean, and tidy on the day of inspection and smelled fresh. 19 Berryfield Road DS0000028389.V364467.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): 32, 34, 35 Quality in this outcome area is adequate. People were supported by sufficient staff who were trained and qualified to meet their needs. People were not protected by the recruitment practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the staff rota. This showed that there were usually two staff on duty 9 am until 6pm. On some evenings, when there were activities or people went to a social club, there were two staff until 10 pm. One member of staff slept in at night. The manager said that they were trying to have more staff at weekends so that people could have one to one attention. Sometimes there were three staff on duty so that people could chose not to go to activities. One member of relief staff had been recruited since the last inspection. The manager told us that their recruitment checks were not kept in the home. They were kept at head office. There was also no record of the checks that had been carried out. When we telephoned head office a few days after the inspection, to arrange to see the records, we were told that the human 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 22 resources manager, who looked after these records, had just gone on leave and would not be back for two weeks. We were also told that no-one else had access to these records so that we could inspect them. We visited the office to inspect the recruitment records on 23rd July 2008. There was a recruitment checklist with some dates of when checks were received. The member of staff had filled in an application form. This contained a declaration that they had no convictions and a medical questionnaire. The checklist stated that the member of staff started work on 7th February 2008. Two written references dated 10th and 19th December 2007, were received before this. Their Criminal Records Bureau (CRB) check, including a check of the Protection of Vulnerable Adults (POVA) list was received on 8th February 2008. The human resources manager told us that the member of staff would have visited the house and talked through expectations and read information. She also said that she thought that the member of staff worked for a fortnight shadowing other staff. A POVA first check was requested on 1st February 2008 but the human resources manager said that this was not received back. The person therefore started work without a check of the POVA list. A risk assessment had been conducted for starting work before a CRB check, which said that all other checks, including two written references and a POVA first check, would be made before the member of staff started work. It was not clear from the checklist when the member of staff started to work with people. We looked at the record of training for all staff. This showed that staff received training in manual handling, fire safety, first aid, food hygiene, infection control, medication, abuse awareness, risk assessment COSHH and person centred planning. The manager reported in the AQAA that new staff had learning disability award training as underpinning knowledge for National Vocational Qualifications (NVQ). The manager also told us in the AQAA that there were five permanent staff. Four had NVQ level 2 and one was working towards NVQ. Two staff who completed surveys said that they had training that was relevant to their role and helped them to understand people’s individual needs. One said that the training kept them up to date with new ways of working but the other one said that it did not. One health professional who completed a survey said that staff always had the right skills and experience to meet people’s social and health care needs. 19 Berryfield Road DS0000028389.V364467.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, 39, 42 Quality in this outcome area is good. People benefited from a well run home, where their safety and welfare were promoted. People were contributing to a review of quality in the home so that the home was run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager had been in post nine years. They had a diploma in social work and the registered managers award. The manager also kept their training up to date. 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 24 The manager told us that all the systems in the home, such as team meetings, tenants meetings and regulation 26 visits by a senior manager, contribute to the quality assurance process. They also said that there was a development plan. We made a recommendation at the last inspection that the policy on quality assurance is developed to include details of how the different devices contribute to the production of an improvement or annual development plan for the home. The manager said that all ideas for this plan came from tenants’ meetings and team meetings. The policy had not been changed and it was not clear how other processes such as the regulation 26 visits contributed to the development plan. The manager told us that the quality assurance development plan was a working tool, which she used every day to monitor the working of the home. This included things like who was having the opportunity to go out, which staff were involved in activities, what environmental changes were needed and any training needs for staff. She had already identified the need for training about dementia and equality and diversity. There was a health and safety policy. We looked at the health and safety measures. There were individual and generic risk assessments and a fire risk assessment. We saw the fire log book which recorded when all the checks of the fire safety measures took place. We noted that all the appropriate checks were being carried out and staff were receiving fire instruction. There was information about Control of Substances Hazardous to Health (COSHH). Portable appliances were tested. 19 Berryfield Road DS0000028389.V364467.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 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)c Schedule 1 Requirement Timescale for action 28/08/08 2. YA34 19 (9) (10) 3. YA34 17 (3) a Schedule 4 The statement of purpose must be updated so that people who are thinking about moving into the home have up to date information about the service provided. When a new member of staff 23/06/08 starts work with people before a Criminal Records Bureau check is received, all other checks, including a Protection of Vulnerable Adults first check must be completed to reduce the risk of people being cared for by unsuitable staff. The recruitment records must at 23/06/08 all times be available for inspection so that we can establish whether people are at risk. 19 Berryfield Road DS0000028389.V364467.R01.S.doc 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. Refer to Standard YA9 YA20 Good Practice Recommendations The risk assessments could be improved by making sure all of them contain information about why people are taking risks and how this benefits the person. A cupboard, which complies with the requirements for the storage of controlled drugs in care homes, should be obtained so that if people are prescribed controlled drugs they can be stored safely. Greater use should be made of outside agencies and trainers in the training that staff receive in areas such as safeguarding adults and medication. This will help to make sure people benefit from up to date practice. When staff recruitment records are kept in the head office a recruitment checklist should be kept in the home for both permanent and relief staff to show when all checks have been carried out and that people are being protected. (Information about arrangements for keeping records in a central office is available on the CSCI website: www.csci.org.uk.) That the policy on quality assurance is developed to include details of how the processes for example, tenants’ meetings, regulation 26 visits and person centred plans contribute to the production of an improvement or annual development plan for the home. 3. YA35 4. YA37 5. YA39 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@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 19 Berryfield Road DS0000028389.V364467.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!