Inspection on 13/04/06 for 1-3 Robin Close

This inspection was carried out on 13th April 2006.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-3 Robin Close 14/12/09

1-3 Robin Close 09/11/07

1-3 Robin Close 08/01/07

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 2-3 Robin Close Westbury On Trym Bristol BS10 6JG Lead Inspector Vanessa Carter Key Unannounced Inspection 13th April 2006 09:30 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 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 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 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. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 2-3 Robin Close Address Westbury On Trym Bristol BS10 6JG 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 9494942 None United Response Mr Simon Charles Phillimore Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (2) of places 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 7 persons aged between 18-65 with learning disabilities May accommodate 2 named persons aged over 65 with learning disabilities Planned alterations to House Number 3 will be completed by the end of November 2006 Planned alterations to House Number 2 will be completed by the end of April 2007 First Inspection Date of last inspection Brief Description of the Service: Numbers 2 and 3 Robin Close provide placement for 7 people, three in number 3 and four in number 2. Both properties are identical, are two storey and are approximately 15 years old. Until July 2005, the properties were owned and run by the National Health Service. At this point, the houses transferred to Golden Lane Housing Association with the care services being provided by United Response, a Chippenham based service. Number 1 Robin Close remains with the NHS. The properties are located within their own gardens but these are currently under developed. The home offers placement to both male and female residents aged between 18-65 years with a learning disability. The fees that would be charged for placement have not yet been determined, as the current residents are all block-contract funded by the NHS. United Response have produced a Statement of Purpose and this will inform any prospective residents about their service. This is the first inspection of the service and therefore there will be no previous inspection reports. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and is the first that the service has undergone. The “home” has until now, been managed by the NHS, and therefore this is the first time the service has been measured against the Care Homes Regulations 2001 and the National Minimum Standards. Evidence has been obtained by speaking with some residents, observations of the interaction between the staff and residents, and discussions with some staff members and the home manager. Some of the home’s records have been examined. Whilst this inspection has shown that the home has major shortfalls in many areas, the resident’s needs are met, and staff are actively seeking to improve the quality of the resident’s lives. What the service does well: What has improved since the last inspection? This is the first inspection of the establishment and therefore this section is not applicable. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 6 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. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 7 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 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Information produced about the home needs minor alteration to enable any future resident or their representative, to make an informed choice about moving to the home. The home’s assessment processes are poor and this may mean that residents will not be looked after as they wish or get the care they need. EVIDENCE: The home has a statement of purpose but this needs some improvements to ensure that any prospective resident, and/or their representative, is able to make an informed choice about moving to live at the home. The document must reflect the service that will be offered, and the quality of life that a resident can expect to have. Residents must be provided with a ‘service user guide’ in an appropriate format that they are able to understand, so that they are fully aware of their rights and how to raise any concerns they may have. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 9 The home is fully occupied - the residents have been living in the home for some time. Since United Response took over the responsibility for the delivery of the care services, they have failed to undertake a comprehensive assessment of each individual’s needs. Two residents files were examined - for one person, the home had started to complete a “life plan” but this in no way provided an overview of the person’s specific needs. This major shortfall has the potential to place the residents at risk, with their care needs not being met appropriately. An assessment of needs is essential in ensuring that the resident’s specific requirements are identified and an appropriate plan of care is written. The manager discussed the proposed admission procedures that would be followed in the case of a vacancy becoming available – this would involve the gathering of information from family, healthcare and social care professionals, and the homes needs assessment. Prior to admission to the home a number of transitional visits would be arranged, so that compatibility with the other residents is measured. This may initially be a “meal time” visit, increasing to a number of hours, to a sleepover and then a weekend stay. In the absence of any assessment process, the home are unable to demonstrate how they would meet a prospective residents needs, therefore should not be offering placements until they have robust procedures in place. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The homes care planning processes are poor and residents are not given the opportunity to have a say in how they want to be cared for. Residents could be at risk from poor risk assessment processes. EVIDENCE: Two of the residents’ files were looked at and neither had an adequate care plan in place. The poorest of the two just had seven statements of what help was needed, “needs help washing” for example, but there was no indication of what level of support or of what action the support staff were to take. The other person’s plan of care contained information that had been written or recorded many years previously. This major shortfall has the potential to place the residents at risk from not receiving the care they require. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 11 Discussion however, with the manager and some of the care staff evidenced that the staff do have an in-depth knowledge of the individual resident’s care needs, but the staff must extend this to include the social and life style support required. Each individual’s plan of care must cover all aspects of personal and social support and healthcare needs and must focus on how each resident can reach their full potential. The plans must be drawn up with the involvement of the resident together with family and/or relevant agencies and where appropriate be made available in an appropriate format for the resident to understand. The plans must then be kept under review, on at least a six monthly basis, and amended where necessary to reflect any changes. There is no evidence that the residents are involved in any of the planning and decision-making processes concerning their lives. The home have on file, a number of risk assessments for each of the residents, but without proper assessment and care planning processes, it is not possible to state that their process is complete. For one person the assessments had been completed in 2003 and reviewed once in February 2005. They also included comments of “take precautions” and “follow available guidelines”. This is not adequate and does not provide staff with clear instructions. This shortfall has the potential to place the resident at risk. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The opportunities, for each resident to develop to their full potential is poor. Improvements in the way that each individual resident is assisted to have a life style of their choosing, will enhance the quality of their lives, and enable them to fulfil their aspirations. EVIDENCE: None of the current residents attend any educational courses or engage in any occupation. Again without any proper assessment, or evidence that residents have been consulted about skills they would like to develop, it is not possible to determine that residents are assisted to have a lifestyle of their choosing. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 13 One resident attends local authority day services each weekday but at other times any activities are arranged on an “ad-hoc” basis and are dependent upon staff and transport availability. The other residents have minimal Activity Plans – two hours day care twice a week. Whilst the residents do use some of the community facilities, so far there is very little opportunity for them to participate in any new experiences. Residents are encouraged and assisted to pursue their own interests and hobbies, where these have already been identified. The manager is fully aware of the need to address this shortfall and sees this as a priority, in order to enhance the lives of the residents. Residents are encouraged to maintain contact with family, and staff will assist with making any of the necessary arrangements. Residents are consulted before anyone goes into their private room – each room is lockable and the resident is able to choose whether to have a key or not. Residents were observed moving about in the home independently and staff were conversing with them appropriately. The residents in one of the houses need to have 1:1 support during mealtimes, but there was very little interaction noted during this time. The home has a well-balanced four-week menu plan. No choices are recorded at each mealtime, however residents can have an alternative if necessary. There is no record kept of food offered to evidence this. Due to the communication difficulties of the residents, it was not possible to obtain their views on the meals they are provided with, or to ascertain whether they have been involved in deciding what meals are prepared. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive adequate help with their personal and healthcare needs but improvements in some of the staff practices, would improve the residents lives. EVIDENCE: The manager and staff team demonstrated a working knowledge of the resident’s specific healthcare and personal needs, but this is based on “how things have always been done”. All residents are registered with the same GP and the doctor visits the home on a weekly basis. The manager explained that these arrangements are part of the agreement between United Response and the Primary Care Trust. One resident was assisted to visit the opticians on the day of inspection, and was helped to choose their own glasses Staff said that the residents are able to get up and retire to bed, at their preferred time. All seven residents were observed, at different times of the day moving about the home, or being given guidance where necessary. The residents were each well dressed and looked clean and well cared for. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 15 When required, they were helped to change their clothing, but this was not done in a discreet manner. It would be more dignified for residents if the approach from staff was sensitive. The home keeps a record when healthcare professionals are consulted about the health of the residents, but there is a lot of historical information in the files and it was difficult to determine what was up to date. The homes medication procedures have given great cause for concern and the CSCI pharmacist has already visited the home and advised the manager. A large number of medication errors have been made, but these have not resulted in any harm to the residents. Strategies have already been put in place to increase the number of medication audits (now done each evening) and a reduction in the number of staff who administer medicines. Staff stated that previously “medications were always administered by the qualified nursing staff” but that they have received training in safe medication administration and that additional training is also planned for the near future. The manager has demonstrated a positive approach in resolving this situation, but must continue to work with the staff team to prevent these incidences. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good procedures are in place to safeguard residents from harm. Strategies must be in place to enable the residents to raise concerns, be listened to and have their concerns acted upon. EVIDENCE: The home has a complaints procedure in pictorial format. Since the residents are not provided with a service users guide, they are not issued with a copy of this. The home may want to consider displaying a copy of the procedure, in a visible area within the premises, to act as a reminder for the residents. Due to the level of the resident’ s individual learning disabilities and communication needs, those spoken with during the course of the inspection, were not able to state that their views would be listened to and acted upon. The home must therefore put in place, measures to ensure that the resident’s wishes and views are sought, in a meaningful way for each individual. The manager has already demonstrated his ability in ensuring that the residents are protected from abuse, harm or neglect. A significant number of incidences of physical aggression and verbal assaults, have occurred between the residents, and the manager has increased staffing levels, and has followed “No Secrets” procedures by involving appropriate local authority personnel. Staff confirmed that they have had training in adult protection issues, and the homes training matrix evidenced that the whole staff team have either had, or will have training, in the near future. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe and comfortable home, but planned changes to the living arrangements will provide them with an enhanced environment that will meet their needs. EVIDENCE: Number 2 Robin Close is home for four people. Two of the bedrooms are on the top floor and two are on the ground floor, along with a large lounge, a smaller quiet room, a dining room, a games room, the kitchen and utility area. There is one bathroom and a separate toilet on each floor. A staircase is the only route between the two floors; therefore the home is not fully accessible to anyone with mobility impairment. Number 3 is home for three people. The building is identical in its facilities however only one person is accommodated on the first floor. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 18 The homes are both to be revamped, with works expected to commence in number 3 at the end of the summer. Building contractors are tendering for the contract at the moment. Number 3 will be converted to 3 self-contained flats, whilst number 2 will have four bedrooms with ensuite facilities of either a bath or shower unit. These changes will enhance the environment for the residents and also ensure that the home meets the national minimum standards. It is expected that the works will be completed in Spring 2007. Both homes are nicely furnished, are well decorated, kept clean and tidy and free from any offensive odours. All furniture is of a robust design, and electrical items are secured in cabinets. The home makes arrangements for any repairs to furniture, or other environmental damage, as necessary and as promptly as possible. Most of the resident’s bedrooms were viewed – each reflected the person’s own personality. The manager explained that where appropriate, the residents will be involved in the “re-designed” of their bedrooms and ensuite facilities. Although the home is primarily for residents with a learning disability, it also cares for those with physical disability. One bathroom is fitted with grab rails to aid a resident and a ramp has been fitted by the patio doors in the lounge to enable access out into the garden. The home currently does not have a call alarm system, however a sophisticated system will be installed in the home, as parts of the works, so that staff can summon help in an emergency. This will be particularly important in number 3 where the resident and staff member will eventually be working within a closed environment. Each staff member will have a “panic alarm” on their person whenever they are on duty. Each house has a utility room housing a washing machine and tumble dryer plus housekeeping equipment. The manager plans to replace the one domestic washing machine with an industrial model. The residents’ washing is attended to individually and this is good practice. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are skilled and knowledgeable therefore residents can expect to be well cared for. EVIDENCE: The existing staff team have transferred from NHS employment under protected terms and conditions of service, but a number of new recruits have joined the team. The home is currently using agency staff to fill some shifts but are actively trying to reduce this usage. The manager stated that where possible, they use agency staff who know the home and the residents. The manager has identified the need for more staff to complete the team, and recruitment is already underway. Discussions with some staff members and observations of their practice evidenced that they are knowledgeable of the resident’s specific needs and have the necessary skills to be able to meet them. The decisions they make about the care of a resident, on a day-to-day basis, is based on the long-term relationship, they have already formed. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 20 The majority of the support workers have already attained an NVQ Level 3 in care, but this has been achieved within a healthcare setting. United Response need to look to provide additional training to ensure staff skills are transferred to a social care environment. In number 3 each of the three residents is assigned a member of staff for the day, plus there is an additional “floating” staff member to assist with any emergencies or outbursts between the residents. Over night there are two members of waking staff in each house, and their shifts commence at 9pm. These arrangements may impact upon the activities of the residents and prevent them from participating in any form of evening recreation. Consideration may be needed in the future to amend the timings of staff duties, as the residents are introduced to more opportunities. The home follows robust recruitment procedures and ensures that the right people are employed at the home. New staff will complete a Learning Disability Award Framework (LDAF) induction programme at the start of employment and evidence was seen of this having been achieved within 8 weeks of employment for one person. Following completion of this, a foundation course will be started. These arrangements will ensure that all new staff will have the necessary skills and attributes to meet the resident’s needs. The manager will be arranging for all staff to have an annual appraisal, in which their training and development needs will be identified and incorporated into the homes training plan. Staff supervision is arranged for the whole staff team and is shared by the deputy and the manager – the manager must ensure that all staff have 1:1 supervision at least six times per year. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. 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. The home has strong leadership and is well run. Improvements in capturing the residents’ views would ensure that the home is run in their best interests. EVIDENCE: The registered manager was present during the inspection visit, cooperated in the process and demonstrated good awareness of the homes procedures and the resident’s needs. He has been in post since the home transferred from NHS retained services to being a Care Home, and has successfully completed the registration process with CSCI. He has previous experience of home management within a United Response social care setting. His main aim at the current time, whilst continuing to ensure that the residents get the care they need, is to lead the staff team through a period of significant change, to assist in the tendering-for-works process, and then the subsequent relocation of the residents whilst building works are underway. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 22 He is currently undertaking the NVQ Level 4 Registered Managers Award but is unable to say when this will be completed, due to the impending changes. It is part of United Response’s means of assessing their home manager’s performance, that they be appraised, by both senior management and the staff team. Staff spoken with during the inspection were positive about the changes the manager is bringing about in the home and felt he provided a clear sense of leadership, but valued their in-depth knowledge of the individual residents. The home has one deputy manager who is responsible for number 2, and recruitment for a deputy for number 3 is underway. Staff meetings are held on a monthly basis. The home has yet to put in place any mechanisms where they capture the views and opinions of the residents, or their relatives and any other representatives. The one relatives meeting so far arranged, was poorly attended. Development of the service is so far restricted to the changes to the internal arrangements of the houses. It is expected that the service will have in place an effective quality assurance and monitoring system, so they are able to measure their success in achieving the aims and objectives, and statement of purpose of the home. The organisation have in place polices and procedures to safeguard and protect the health and well being of the residents. Not all the homes records are maintained adequately. Staff personnel records evidenced a robust recruitment procedure for newly appointed staff. A training file is not kept for each staff member that evidences their qualifications and shows the training courses attended. The records kept in the home in respect of each resident are out dated and have a very poor quality. Whilst the recording of any accidents/incidents is good, there is no record to evidence how often a particular event occurs with each resident. This does not allow the manager and staff to look for any trends or trigger factors. It would be good practice for an “incident log” to be maintained alongside the accident/incident forms. The home does notify CSCI of any incidences that occur within the home. The fire safety records were in order, but it was difficult to determine that the ‘night staff’ have had training at the recommended intervals (three monthly). Since the staff group cover both day and night shifts, it would be good practice for them all to have instruction on a quarterly basis. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 23 The records of other environmental checks were generally in order, but where checks on hot water temperatures were found to be outside of the safe range, there was no evidence that any action had taken place. All staff receive first aid, food hygiene, infection control, and moving and handling training. The homes training matrix showed dates when staff have attended the training or are due to. Staff spoken to confirmed they have received mandatory training since the service became a care home. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 24 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 1 3 1 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 1 3 1 3 X 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 5 Requirement An up to date service users guide, in an appropriate format, must be available for residents and their representatives Each resident must have had a comprehensive needs assessment, by a competent person, to identify his or her specific care needs. Each resident must have a plan of care that highlights their needs, details how these should be met and what actions the staff should take This plan should be kept under review, at least six monthly. All risk assessments must be up to date and kept under regular review. Each resident should have a meaningful plan of weekly activities, that they have chosen to participate in. Staff must maximise residents privacy and dignity, and control over their lives, at all times. All staff must be competent to safely and correctly administer medicines as prescribed by the GP. DS0000063643.V289054.R01.S.doc Timescale for action 13/07/06 2 YA2 14(1,2) 13/07/06 3 YA6 15 13/07/06 4 5 YA9 YA13 13(4)b 16(2)m,n 13/07/06 13/10/06 6 7 YA18 YA20 12(1-5) 13(2) 13/05/06 13/06/06 2-3 Robin Close Version 5.1 Page 26 8 YA22 22 9 YA39 24 10 YA41 17 The home must have systems in 13/06/06 place whereby residents know they are able to raise concerns and will be listened to. The home must have effective 10/11/06 quality assurance and monitoring systems in place to ensure the service remains appropriate to the residents needs. All the homes records should be 13/07/06 accurately maintained, showing action taken where necessary, and be able to provide an audit trail when required. 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 5 Refer to Standard YA7 YA16 YA17 YA33 YA41 Good Practice Recommendations Residents should be involved in planning their own care and having a say in how their needs are met Residents should be consulted and involved in the daily routines and running of the home where possible. Residents should be consulted in meal planning and records should be kept where alternatives are offered. Alterations should be considered in the staff shifts, when residents participate in more social activities. An “incident log” to be maintained alongside the accident/incident forms. 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bristol North LO 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. Extracts may not be used or reproduced without the express permission of CSCI 2-3 Robin Close DS0000063643.V289054.R01.S.doc Version 5.1 Page 28 - 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!