Inspection on 25/10/07 for 2 - 4 Wraxall Road

This inspection was carried out on 25th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 - 4 Wraxall Road 29/11/06

2 - 4 Wraxall Road 21/12/05

2 - 4 Wraxall Road 18/05/05

2 - 4 Wraxall Road 20/10/04

2 - 4 Wraxall Road 05/04/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 2 - 4 Wraxall Road Cadbury Heath South Gloucestershir BS30 8DN Lead Inspector Grace Agu Key Unannounced Inspection 25th October 2007 09:15 2 - 4 Wraxall Road DS0000020293.V348178.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 2 - 4 Wraxall Road DS0000020293.V348178.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. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 - 4 Wraxall Road Address Cadbury Heath South Gloucestershir BS30 8DN 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 9600430 0117 9605295 ian.cameron@brandontrust.org www.brandontrust.org The Brandon Trust Mr Ian David Cameron Care Home 14 Category(ies) of Learning disability (14), Physical disability (14) registration, with number of places 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 14 persons aged 18 years and over with physical disability and learning disability who require nursing care Staffing Notice dated 03/03/2000 applies Manager must be a RN on parts 5 or 14 of the NMC register. Date of last inspection 29th November 2006 Brief Description of the Service: Brandon Trust operates 2 - 4 Wraxall Road, which is registered to provide nursing care to 14 adults with a learning disability and a physical disability. The property is located in a quiet residential area, close to local shops and amenities. The houses are purpose built and equipped for disabled people. There are 14 single bedrooms of various sizes. There are parking spaces and grounds to the side and rear of the house. Fees range from £1110 to £12220 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which was undertaken as a part of key inspection over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection seven requirements were made in relation to care planning updating the complaints procedure, training and ensuring that the risk assessments are regularly reviewed at the home. Other requirements issued included ensuring that medication practices are in line with the home’s medication policy. It was pleasing to note that the home has made efforts to ensure that most of the requirements were met. The manager stated that the home is working towards meeting the remaining requirements. I met with two trained nurses. The home Manager Ian Cameron arrived later in the day and assisted with providing information for the rest of the inspection process. Whilst touring the building, we observed a number of residents; spoke to three support staff and a number of records were viewed. What the service does well: On the day of the visit we found the home to be clean, tidy, warm, well lit and free from unpleasant odours. The home had a general relaxed and homely atmosphere. Residents looked well cared for and despite their profound learning and physical disabilities staff were noted interacting with residents in an informal, respectful, personalised and dignified manner. In order to ensure adequate nutrition for residents, good meals are provided and are not hurried. The inspector observed the residents at lunchtime and noted that those who use the service were fed with respect and sensitivity. Individuals who were able to feed themselves were assisted as required without compromising their independence. The Home provides varied meaningful and stimulating activities and outings for the residents and ensures that individual interaction is provided as a routine and as necessary. The home has a well-established team of trained nurses and generally a stable work force that treats the residents with respect. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 6 Whilst the residents are unable to tell us how if they are happy with the services provided at the home due to their profound Learning disabilities, the feedback we received from their relatives through the comment cards were positive. These comments include: “My relative is well looked after I am very happy. “They care for my son extremely well”. “They take away all my concern and worry from me, they do everything that I long to do but at 80 quite unable to do. They are wonderful”. “I am quite pleased with how my son is looked after”. “I know my son is safe and happy his carers look after him very well and keep him tidy, plus they always keep me informed about my son”. “The care home does very well with all the people living there. Comments from health professionals include: “Well run home, efficient and caring set up. No concerns at all after 8 years of regular work”. “Very caring staff, well run, no concerns. What has improved since the last inspection? What they could do better: Residents handling equipment noted with rusty and flaking handles must be repaired/replaced to prevent potential injury to the residents and staff. Furthermore shower trolley must be kept clean at all times in order to promote effective infection control. To ensure that a resident’s need is adequately met, care plans must be developed and in agreement with individual’s family or representative in relation to weight loss to ensure that the home is able to meet their needs. To ensure that residents are protected, all hand written medication must be signed and dated and, all medication must be correctly labelled from the 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 7 pharmacy and must correspond with the entry on the Medication Administration Record Sheet (MARS). We observed whilst reviewing medication that the recording of the medicines fridge temperature was unsatisfactory. According to the records seen the average fridge temperature readings was minus two degrees Celsius since January 2007. This is hazardous to the medicines stored in the fridge. The home must ensure that the fridge is repaired or replaced in order to protect the service users’ medicines. Furthermore we also observed whilst touring the building that the recording of the fridge and freezer temperatures in both kitchens were inconsistent. In order to minimise the risk of food poisoning to the service users staff and visitors the home must ensure that there regular recordings of the fridge and freezer temperatures. 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. 2 - 4 Wraxall Road DS0000020293.V348178.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 2 - 4 Wraxall Road DS0000020293.V348178.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): 2 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The home has a detailed and well-planned admission process to enable prospective residents to make an informed choice about moving into the home with the assurance that their needs would be met. EVIDENCE: There has been no new admission to the home since the last inspection. However if there were a proposed admission, residents would be assessed at an early stage to consider if the home could meet their care needs and if they are compatible with the other residents. There was a comprehensive care management assessment in place in two residents’ care files reviewed. The residents have not been able to be involved in their care documentation due to their profound Learning and physical disabilities. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individualised care plans are provided for the service users to reflect their assessed needs and are supported with risk assessments to live much independent lives as practicably as possible with the assurance that information about them will be kept confidential. EVIDENCE: We randomly reviewed in detail the care documentation of two individuals living in the home. The two care files had comprehensive care management assessments. The care needs indicated in the care management assessment had been reflected in the home’s documentation and had been reviewed regularly. There are risk assessments with regards to various areas of health and personal care and these were reviewed regularly. Staff were able to demonstrate awareness of risk for individual service users in the home, which 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 11 includes the balance between maintaining the safe environment and enabling people who use the service to express choice. The personal profile of the individuals and assessments were well written providing staff with information on how to determine the individuals’ preferences and dislikes. Whilst it was difficult to involve the service users in the decision making process due to their profound learning disabilities the interaction between staff and the people who use the service was service user focused. Staff were able to acknowledge the service users individual abilities and needs. At a discussion with staff met on the day, the inspector was informed that through observation such as facial and/or vocal expression staff enable the people to make choices. Staff also acknowledged that they have to make choices and decisions on behalf of the services users and are mindful about how they do this in order to safeguard the peoples’ welfare and rights. The inspector had the opportunity to observe staff feeding the people who use the service at lunchtime. Staff were able to discuss the physical and mental wellbeing of the individuals and confirmed that the General Practitioners and other health professionals would visit the home whenever required. None of the residents is likely to go missing as total support is required for all the individuals and staff always accompany the service users on all external activities. The home has a confidentiality policy. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15,16,17 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain links with the community, family and friends. Their individual rights are protected and the home provides them with healthy diets at chosen times. EVIDENCE: The home is located in a residential area within a short distance from the local shops and amenities. The home has it own transport that is used by staff and day care staff for service users’ recreational activities and holidays. The inspector noted from discussion with staff and reviewing the care files that people who use the service are supported to lead active lifestyles based on their level of understanding and choice. The manager stated that all the service users have a planned activities programme, which is supported by day care and staff in the home. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 13 There is a designated room in the home, which is equipped with sensory lights and imagery; three service users were noted being supported to participate in activities. The individuals looked relaxed and seemed to be enjoying the company of each other. There was evidence that service users have regular contact with families. Relatives told us in the survey sent to them that they are satisfied with the care provided at the home. One family stated that they visit every week in order to maintain contact with their relative. Through observation and discussion with staff, it was evident that people living at the home are treated with respect and dignity when receiving personal care. One staff stated that they are aware of the needs and preferences of the individuals and despite the fact that it is difficult to establish the level of understanding of each individual due to disability, staff continue with normal conversation and are often able to expect responses based on knowledge and experience of caring for the individuals. 2-4 Wraxall Road has a kitchen/ dinner on each unit of the home, which is domestic in style. Staff stated that meal times are generally flexible to take into account the activities of the individuals and staff in the home. One staff member stated that all the residents need assistance with their meals and that staff are well aware of eating habits of individual resident. For example some residents may be reluctant to eat or drink if they were being assisted by a staff member who was unfamiliar to them. Records show that menu is the planned on a four weekly basis. The inspector was informed that all the individuals require liquidised meals. This was noted to be appropriately and attractively prepared. The kitchens on both units were found clean and tidy The manager stated that kitchens were recently refurbished. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents receive preferred personal support as required, their emotional and physical health needs are met also respect is given to their wishes in the event of death, however lack of specific care planning and unsatisfactory medication practices at the home fail to protect residents. EVIDENCE: The people who use the service are dependent on the care and nursing staff to meet their care needs with the care documentation in place to guide staff. Personal care is provided in private and respects the dignity of the resident. Staff were noted knocking at the door when providing the individuals with personal care. A key working system operates well in the home. One staff member stated that two support workers and a coordinator support two individuals living in the home. Whilst the people are not able to contribute due to the learning and physical disabilities, staff ensure that they are included in the review meetings. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 15 One staff member spoken with gave a comprehensive account of how personal care is given to the resident with very complex needs. The staff member stated that staff are aware of the individuals’ facial vocal expressions, which would normally indicate how the individual is feeling. The staff member stated that she had worked at the Home for many years and knows the individuals very well. However, records of a service user show that the individual had lost weight over a period of three months. There was no care plan developed with the representatives to enable staff to meet this need. This was discussed with the manager and a requirement was made for the home to put a plan to guide staff in regards to supporting the individual to prevent further weight loss. The care files showed evidence of regular GP and other professional visits including reviews. There are clear procedures and appropriate arrangements in place for the receipt, storage, administration and disposal of medication in the home. The system was found generally satisfactory. However some handwritten medication records were not signed and dated. Furthermore a medication labelled as directed from the pharmacy had a different instruction on the Medicine Administration Record Sheet (MARS). We also observed whilst reviewing medication that the recording of the fridge temperature was unsatisfactory. According to the records seen the average fridge temperature reading was minus two degrees Celsius since January 2007. This is hazardous to the medicines stored in the fridge. The home must ensure that the fridge is repaired or replaced in order to protect the service users medicines. These discrepancies were discussed with the manager and a requirement was issued for the above to be remedied in order to protect the residents. Staff demonstrated knowledge of how to treat residents when they are terminally ill and the procedure in event of death. The Home has a Death and dying policy. The care files viewed showed evidence of risk assessments in relation to the care needs. Individual needs with regards to specialist equipment are clearly met and regularly reviewed. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 16 Risk assessments in relation to using the equipment was provided for all transfers. 2 - 4 Wraxall Road DS0000020293.V348178.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 This judgement has been made using available evidence including a visit to this service. The residents are enabled to complain with the confidence that their views will be listened to and acted upon and that they are protected from abuse. EVIDENCE: There is a complaints procedure available in the home. The document contains information about the Commission for Social Care Inspection and is in an appropriate format relevant to the service users group. Individuals living in the home would not be able to complain due to their profound learning disabilities however staff spoken with were able to demonstrate how they might know that an individual is not happy through facial and vocal expression and changes in their behaviour. Relatives told us in the comment cards sent to them for their views about the care provided at the home that they would complain to the management on behalf of the people who use the service. No complaint was recorded since the last inspection. Staff spoken with demonstrated awareness of the Whistle-blowing policy. There is a Brandon Trust policy and procedure in regards to the Protection of Vulnerable Adults 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 18 The Home also has a copy of South Gloucestershire’s policy and procedure for the Protection of Vulnerable Adults. Staff records viewed evidenced that staff have attended training on the above subject. Two staff spoken with were well aware of abuse issues and would report any suspected abuse to the manager regardless of who was involved. Two residents’ monies were reviewed. The residents’ monies in the purse were correct and balanced with the records. 2 - 4 Wraxall Road DS0000020293.V348178.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. The home provides a homely and comfortable environment for the residents with specialist equipment. It provides clean, safe and hygienic equipment to protect the individuals. EVIDENCE: Major changes to the building had not occurred since the last inspection. The home remains suitable for its stated purpose. The Home was found clean tidy in a good decorative order and free from offensive odour. The communal areas and bathrooms were found to be clean, tidy and spacious to meet the needs of the residents. The home has basic sluicing facilities. The laundry facilities and practices were seen to be satisfactory. The home has a policy on infection control and staff were noted washing their hands after attending to the service users. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 20 However, it was disappointing to note whilst touring the building that three shower trolleys were found very dirty with build up of grease and have not been kept clean after each use. This practice is not acceptable and exposes the people living in the home to potential risk of infection. This was discussed with the manager and the trolleys were cleaned before the end of the visit. The home must ensure that this is carried out consistently. 2 - 4 Wraxall Road DS0000020293.V348178.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 good. This judgement has been made using available evidence including a visit to this service. Residents are assured that competent staff are recruited and supervised; the home protects them by providing sufficient training for its staff and regular supervision. EVIDENCE: There is a well-established skilled and experienced staff team at the home to meet the needs of the individuals living in the home. One staff member stated that they had been in the home since it opened. The staff member was able to demonstrate understanding and knowledge of the care needs of individual service users. Review of the rota on the day of the visit evidenced that the home had satisfactory numbers of staff competent to meet the needs of the people living in the home. Registered nurses are employed by the home. The manager stated that seven support staff have achieved National Vocational Qualification (NVQ) at level 2, 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 22 three support workers have NVQ2 and 3, three are undertaking level 2 and four are undertaking level 3. The Trust has robust recruitment and employment policies and procedures in the home. Two staff records viewed contained satisfactory recruitment documentation to ensure residents are protected. Staff records viewed and discussion with staff evidenced that staff are receiving regular supervision to ensure that all areas in relation to the roles and responsibilities are appropriately addressed to meet the needs of the individuals living in the home. There is also evidence that the Personal Identification Numbers of the Registered nurses had been verified with the Nursing and Midwifery Council Staff training records viewed and discussion with staff led us to believe staff have attended training on manual handling, fire safety and food hygiene. One staff member stated that she had attended training on PEG and naso-gastric feeding to enable the staff member to provide specific care to the individual concerned. 2 - 4 Wraxall Road DS0000020293.V348178.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 adequate. This judgement has been made using available evidence including a visit to this service. A competent leader who safeguards the rights and interests of residents and also protects them through the application of policies, procedures and good recording keeping manages the home. However, some health and safety practices do not protect the people living in the home. EVIDENCE: An experienced and well-qualified home manager manages 2-4 Wraxall Road. Mr Ian Cameron, the Registered Manager is a qualified nurse and possesses a Certificate in Management Studies. Staff spoken with provided positive feedback about management of the home. Staff felt that the manager was supportive and approachable and well respected by the team. 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 24 Staff also stated that there is a well-established team of staff at the home who are very supportive of each other. On the day of inspection, there was evidence of a friendly and interactive atmosphere in the home. Residents looked well cared for and staff were noted interacting with the residents in an informal, dignified and respectful manner. The manager was unavoidably absent in the morning on the day however, two senior staff members met on the day showed satisfactory leadership qualities and assisted professionally with the smooth running of the home and the inspection process before the arrival of the manager later in the afternoon. The systems for reviewing the quality of the service were discussed with the manager. In addition to feedback from relatives, social services reviews, care plans and house meetings; Brandon Trust has its own quality review document. This document is used by the manager and an action plan is developed on how to meet the shortfalls. The fire logbook is up to date and in order. The record shows that the inspection of fire fighting and fire alarms systems and fire safety training for staff has been carried out. One staff member was concerned about the home’s evacuation procedure. The individual was referred to the Trust to contact the Fire Brigade to clarify the situation. There is a Health and Safety policy in the home that and contains information about Control of Substances Hazardous to Health (COSSH) to guide staff on action to be taken in emergency. It was also noted that the handles of three shower trolleys had rust and rough edges, which is hazardous and capable of causing injury to the individuals. A requirement has been issued for these pieces of equipment to he repaired or replaced in order to protect the people who use the service. Furthermore we also observed whilst touring the building that the recording of the fridge and freezer temperatures in both kitchens were inconsistent. In order to minimise the risk of food poisoning to the service users staff and visitors the home must ensure that there is regular recording of the fridge and freezer temperatures. Accident records were reviewed and were found satisfactory. There are appropriate maintenance records in the home. The inspector was shown the Gas certificate, and current Electrical Installation Safety certificate. 2 - 4 Wraxall Road DS0000020293.V348178.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 X 2 3 3 X 4 X 5 X 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 3 3 3 3 X X 2 X 2 - 4 Wraxall Road DS0000020293.V348178.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. 2 3. Standard YA18 YA42 YA20 Regulation 15. 23.2 (c) 13.2 Requirement Ensure all care plans are in place for identified individual. Repair or replace three wheeled shower baths with rusty handles. Ensure all hand written medication on MARS are signed and dated. All medication must have clear instruction from the pharmacy and must correspond with the MARS. Fridge and freezer temperatures must be regularly recorded. Ensure the wheeled shower bath mat is kept clean at all times. Timescale for action 25/11/07 25/11/07 25/11/07 4. 5 YA42 YA30 13.4 13.2(c) 25/11/07 25/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 27 2 - 4 Wraxall Road DS0000020293.V348178.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, 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 2 - 4 Wraxall Road DS0000020293.V348178.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!