Inspection on 12/01/07 for 2 Princess Close

This inspection was carried out on 12th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

2 Princess Close 01/04/09

2 Princess Close 08/04/08

2 Princess Close 13/06/07

2 Princess Close 11/01/06

2 Princess Close 26/09/05

2 Princess Close 03/03/05

2 Princess Close 26/08/04

2 Princess Close 11/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOMES FOR OLDER PEOPLE Princess Close 2 Princess Close Keynsham Bath & N E Somerset BS31 2NG Lead Inspector Sarah Webb 12 th & Key Unannounced Inspection 18th January 2007 10.00 X10015.doc Version 1.40 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 Princess Close DS0000008176.V312065.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Princess Close Address 2 Princess Close Keynsham Bath & N E Somerset BS31 2NG 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 9077222 0117 9699000 www.brandontrust.org The Brandon Trust Ms Heather Hinton Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Accommodate and provide personal care to 1 named person under the age of 65 Date of last inspection 11th January 2006 Brief Description of the Service: 2 Princess Close is a detached house, situated in a quiet cul-de-sac, in a residential area of Keynsham. The house has been extended to provide accommodation for five people with learning disabilities. There is currently full occupancy. There is an agreed variation in the conditions of registration permitting the accommodation of a named service user under the age of 65. On the ground floor there is a lounge, kitchen and dining room. Also on this floor are two bedrooms, a toilet, utility area, and a walk in shower. There is a stair lift to the first floor where there are three bedrooms, a large fourth room currently used as a staff sleep-in/meeting room and a small office space. There is also a bathroom with specialist bath and separate toilet. At the rear of the property, there is a patio and small garden that can be accessed by means of a ramp. The home is within easy access of local amenities that include a leisure centre, shops and a park. There are accessible transport routes to both Bath and Bristol by both bus and train, and there are bus routes to other local areas. Charges range from £682.60 to £931.91 Princess Close DS0000008176.V312065.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 inspection and was carried out over a period of 12.5 hours. The inspection methods used included record and documentation checks, case tracking, and discussion with the manager, a senior development officer and four staff. All five residents were at the home during this visit. A few of the residents’ views were obtained; those spoken with said they were happy living at the home and that they liked the food. There were some residents who did not contribute verbally towards the inspection process. Significant time was spent observing those residents during the visit. The home has complied in meeting the requirements and recommendations from the previous inspection. Due to an agreement in place between the Commission and the Brandon Trust, all staffing records are kept at the Trust’s headquarters and are available for inspection; a previous requirement for staffing records to be kept at the home is withdrawn. Prior to this visit the manager completed a questionnaire that provided information about residents, staffing, fees and confirmation of policies and procedures in place. Surveys were sent to residents prior to this visit and completed with the assistance of staff; relatives comment cards returned to the Commission were positive about the home and the care offered to residents. What the service does well: Staff have good relationships with relatives and feedback from relatives comment cards was that the residents needs are met and that the home communicates any changes. Staff support residents at mealtimes in a respectful manner. Residents have varied and nutritious meals and have been supported through a specialist service in advising staff in how to support individuals safely. The home’s administration of medication is well managed. There are procedures and protocols in place to safeguard the financial interests of the residents. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home must both update and review a resident’s care plan and set out in detail the action needed to be taken by staff to ensure all aspects of their health, personal and social care needs are met. The home must develop risk assessments for residents in relation to their lifestyle including vulnerability in relation to their access to hot water, the risk of choking, falls and accessing the community in order to ensure residents are supported safely in taking risks. The home must review and make arrangements to provide meaningful and social activities for those residents who remain at home without any planned activities and for the daily routines of the home to offer more choice; to consult with residents about activities they wish to be involved with and that are available. The home must develop written strategies and carry out risk assessments for those residents who present agitated behaviour in order to support them safely. The home must ensure all staff are trained in order to update their knowledge and practice in relation to the prevention of residents being harmed. The home must respond to agreed action plan recommending development of a more open and inclusive environment through a consultative approach. The home would improve good practice if care documentation was signed/dated in order to monitor changes and in the review of the staff teams training needs in order to ensure that staff receive appropriate training to the work they perform. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 7 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. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed needs of residents are met to enable an effective admission and ongoing provision of care in line with contractual obligations. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Three residents have lived at Princess Close for many years whilst the other two residents have lived at the home for four and two years respectively. There was documentation in place evidencing that assessments have been carried out for individuals by their funding authority. The home is waiting for a needs assessment to be completed for a resident who has had significant changes to their health over the past year, the manager said that currently the home is able to meet this persons needs as their health has improved. However, it was evident through observation of records and discussion with both the staff and the manager that if their health Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 10 deteriorated rapidly as before, then the home would have difficulty in meeting their needs. Care files identified that residents are referred to specialist services if needed in order to assess the individuals’ needs and support staff with professional advice and guidance. A requirement has been met to follow up an assessment made by a specialist service in order to support a resident safely with their personal care. The majority of the staff team have worked at the home for several years. Those staff spoken with related their previous experience in working with both older people and people with learning disabilities and how they supported the residents with their lifestyles. Examination of residents files evidenced that each has received an updated contract outlining the terms and conditions of their stay. The home does not admit people for intermediate care. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents care plans set out in detail the action needed to be taken by staff to ensure all aspects of their health, personal and social care needs are met. The physical and emotional health needs of individuals are well met through multi disciplinary working. Residents’ benefit from robust measures relating to the administration of medication. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Residents care files are divided into two sections; Person Centred Plans include differing aspects of individuals’ needs such as communication, eating and Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 12 drinking, health, mobility and relationships. Personal Plans include preferences, and making choices. All five care plans were examined and identified that all care plans had been reviewed on a regular basis bar 1. This care plan did not reflect how a resident’s changing needs were to be met, and presented out of date information in relation to their preferences, and support needs. A requirement is made to both review and update care plans on a regular basis in order to reflect changing needs and inform staff of action to be taken. The home also must further develop risk assessments for residents in areas of those susceptible to falls, accessing the community and road safety. Through both observation and discussion with the manager and staff it was identified that a resident needs support with their communication. The manager has followed up advice from a specialist service in implementing a specific signing programme so that all staff are consistent in their approach. Personal Health records contain relevant information regarding residents past history, mobility, daily routines and medication administered. Healthcare notes identified that residents’ access doctor, chiropodist, opticians, and podiatry clinic. The manager said that a health care support worker employed by a local authority is planning to visit the home to monitor individuals’ health. Care files indicated that residents’ psychological health and medication prescribed is monitored regularly through access to specialist services. A recommendation is also made to take out old information and file elsewhere, and sign and date care documentation in order to monitor progress. Examination of residents’ medication profiles identified the arrangements for the administration of medication. Medication is administered through a monitored dosage system; processes to record the receiving, administering and disposal of medication were up to date and signed by staff as were the procedures for weekly stock checks and daily monitoring. There are no residents who self administer. A recent complaint lodged with the Trust relating to practice in supporting a resident at night has prompted the manager to arrange for a specific assessment by a specialist service. The home is to be advised of the outcome of the assessment as to future practice. In the interim the home has made appropriate arrangements to support this individual at night. Staff were observed attending to residents during the day; they were polite and respectful. It was identified that one resident enjoys spending time in their room; staff were observed knocking on their door before being asked to enter. All four comment cards returned from relatives indicated that they are kept informed of important matters and that they are satisfied with the overall care provided. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15. Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from involvement in meaningful and social activities both in the home and in the local community. Residents are supported in maintaining contact with their families. There are procedures and protocols in place to safeguard the financial interests of the residents. Dietary needs of the residents are well catered for with a balanced and varied selection of food available. EVIDENCE: There are two residents who are involved in the routines of daily living at Princess Close. One resident enjoys helping with household tasks such as vacuuming whilst both residents are involved in helping with their laundry. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 14 The residents are involved with informal discussion on a weekly basis and that includes asking residents if they are happy about the choice of food, activities, and future holidays. The manager said she has been concerned that evening meal times were being prepared too early and that this triggered residents in wanting to go to bed early. Discussion has taken place with staff regarding the need to interact with residents’ in the evening in order to offer stimulation unless a choice is made to retire to bed. Daily records gave information of when residents have been supported in accessing the community such as visits to garden centres and out for lunch. All residents bar 1 are wheelchair users allowing one staff member to take out 1 person at a time. One resident accesses a day service three days a week whilst another has 1:1 support for 10 hours during the week. Staff identified that they access the local community and other placements. Two residents have not retained their individual day support, whilst another also has none. Residents were seen to be sitting in the lounge for most of the day with either the television, radio or compact disc player available for stimulation. It was evident that staff had both household, driving and paperwork duties to complete and that there was a conflict in finding time to support individuals on a 1:1 basis and in accessing the community. Through observation of the residents during this visit it was evident that the home must review both meaningful and social activities for those residents who remain at home without any planned activities and for the daily routines of the home to offer more choice. This area was discussed with the manager who is aware of this shortfall and indicated the home wants to improve in this area; that the staff team have agreed action from a team meeting to investigate opportunities for residents to be involved in differing activities. A senior manager spoken to during this visit also said an agreed action is also in place to look at introducing supernumerary shifts for staff in supporting residents on 1:1 basis. Although the home now has a strategy in place to improve, a requirement is also made for the home to consult with residents about their social interests and make arrangements to enable them to engage in local, social and community activities. Staff on duty did ensure residents had refreshments on a regular basis and that their physical needs were met. However, through discussion with the manager and a member of staff, it was evident that one staff member had organised various social activities for one resident meeting their interests. On the day of the visit they were going to a pantomime. The organisation has procedures in place to support individuals with the handling of their financial affairs. All residents are supported in accessing their finances through appropriate policies and procedures. The home has undergone a recent financial audit. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 15 All residents bar 1 are supported with their mealtimes and staff said supervision is essential in order to prevent residents from choking. Staff also indicated that the mealtimes at the home had been difficult to manage but that this had improved through a recent team meeting that set an agreed strategy. This action has followed a complaint lodged with the Trust regarding the practice at mealtimes, and has looked at all aspects of this and how residents are supported. The midday meal was observed; the two staff on duty were consistent in their approach in reminding individuals to slow down whist eating yet being respectful. A specialist service has also been involved in advising the staff in methods of approach. Risk assessments for those residents who may choke were in place except for 1 resident. A requirement is made to further develop a risk assessment for this person. Menus examined indicated that residents are offered a range of varied and nutritious food over a 4 week period. A requirement has been met for a record to be kept of alternative meals offered. The manager said that current menus reflected residents’ choices and the constraints of what was suitable regarding the issue of residents choking. The manager has consulted with a specialist service and followed advice by a dietician. A staff member said they felt the menus were repetitive. However, agreed action set at a team meeting has broadened the opportunity for menus to be reviewed on a regular basis at residents’ meetings and with staff and to update advice from both specialist service and dietician. This is good practice. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has appropriate procedures in place in order to respond to any complaints made. The home must improve in the arrangements in place to protect individuals from abuse. EVIDENCE: There is an organisational complaints policy and procedure that indicates time scales to respond to complaints. The home keeps a written record of all complaints. There have been 2 complaints recorded since the last inspection; these have been dealt with appropriately. A recent complaint was lodged with the organisation regarding work practices at the home and this has now been fully investigated by a senior manager. The findings of the investigation have identified that although certain aspects of the home’s practices need to be reviewed and changed to reflect both good practice and a positive culture, generally residents’ best interests are considered highly. An action plan has been set out by staff through a team meeting to review current practices and instigate how these changes can be met. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 17 There are appropriate policies and procedures through The Brandon Trust to ensure the protection of vulnerable adults and since the last inspection the home has followed the appropriate procedures under this process. The manager said that all staff bar 1 had attended training for the protection of vulnerable adults. A requirement is made for the remaining staff member to attend this training. A newer staff member also said the issue of abuse had been covered during their induction period. Although staff were able to explain the home’s procedure in dealing with an individual’s verbal aggression the home must develop written reactive strategies and risk assess those residents who present agitated behaviour in order to support them safely. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home presents a comfortable, clean and homely environment. EVIDENCE: The home is in keeping with the local community, and is near to local shops and amenities. There are bus services available for access to other local towns and to Bristol and Bath. The home provides a suitably furnished environment that meets the needs of individuals. The staff follow a specific rota for ensuring cleaning tasks are carried out. The home presents a high standard of cleanliness with all areas clean, hygienic and odour-free. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 19 Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported through appropriate numbers of staff on duty. There are processes in place for staff to be deemed competent through a National Vocational Qualification. The home follows procedures for checking there are robust recruitment processes in place. Residents benefit from a staff team who are up to date with statutory training. EVIDENCE: The home provides two staff on duty during the day and early evening. There are 5 care staff currently employed at the home. The manager said there are 52.5 hours vacant that have been covered through a regular bank worker. Inspection of the rota evidenced that appropriate staff were on duty and the same bank worker was used regularly. The manager is interviewing shortly for a fulltime support worker to fill the vacant hours. As previously recorded in Standard 12 an agreed action is also in place to look at introducing supernumerary shifts for staff in supporting residents on 1:1 basis during the day. This will then meet Standard 27.4 of the Minimum Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 21 Standards that states additional staff are on duty at peak times of activity during the day. One staff member sleeps in during the night. The home’s call bell system is located in a previous sleep in room. A member of staff indicated that although this facility was now not available in the current sleep in room/office area, all the residents could be heard at night. This was evidenced through discussion with staff who gave examples of when they had responded to residents waking during the night. One staff member holds a nursing qualification, whilst another is in the process of completing National Vocational Qualification Level 2. Two newer staff are in the process of completing the Learning Disability Framework Award prior to being registered for a National Vocational Qualification. The home has not met the target for 50 of staff to be trained in a National Vocational Qualification or equivalent, however with the newer staff registering this will reinforce the home’s commitment to meeting this Standard. An agreement has been made with the Commission for staffing records to be kept at the Trust’s headquarters. The manager follows procedures in place to implement regular record checks on those staff working at the home. A check list identified that the manager has complied with this and has ensured that records such as references and police checks have been made prior to staff being employed. The training matrix evidenced that staff have received statutory training in food hygiene, manual handling, and first aid. Other areas of training attended include epilepsy, communication, person centred planning, and understanding dementia. Training records evidenced that staff have not attended any training as yet for this current year; the manager said this has been due to vacant staffing hours. There was no evidence to suggest that staff were not competent in supporting the residents, however a good practice recommendation is made to review the training needs of the staff team in order to ensure that staff receive appropriate training to the work they perform. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 35 & 38 Quality in this outcome area is adequate. Residents benefit from living in a home that is run by a manager who carries out their responsibilities well, however improvements need to be made in ensuring that this is done in an open, positive and inclusive atmosphere. Residents’ financial interests are safeguarded. The home has arrangements in place to promote and protect the health and safety of tenants and staff must risk assess areas of residents vulnerability. EVIDENCE: The manager is a qualified social worker who has worked in the field of learning difficulties since 1987. She has completed the NVQ level 4 and the Registered Managers Award. She also is an NVQ assessor. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 23 Ms Hinton has updated her training since the last inspection and has undergone training in the protection of vulnerable adults, stress management, interviewing skills and epilepsy. There are organisational policies and procedures in relation to safeguarding residents’ financial affairs. All residents are supported with their financial transactions. All residents’ monies are paid directly into bank accounts. Residents’ finances are also monitored through unannounced visits and annual financial audits. It was evident through examination of the fire safety log that fire training, fire drills and checks on the fire equipment have taken place. The Risk assessment log listed generic hazards for both staff and residents such as using kitchen and domestic equipment, food preparation, and laundry. The staff carry out temperature checks on hot water outlets. Discussion with a staff member indicated that the one resident who is independent regarding their bathing’ checks their own hot water prior to bathing. A requirement is made to risk assess their vulnerability in relation to this practice. A substance inventory was in place detailing products used, and appropriate data sheets. The home keeps records of accidents and complies with informing the Commission for Social Care Inspection in respect of accidents and incidents occurring in the home. A recent investigation of a complaint lodged with the Trust has highlighted that some aspects of the home’s leadership need to be improved; in communicating a clear sense of direction for staff and residents and that the processes of managing the home are ‘open’ with decision making processes in place. The majority of the staff are supportive of the manager, with an action plan now in place to address those areas previously recorded. With monitoring by the service development manager, the home is set to make improvements. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 x x 3 x x 2 Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement Update and review residents care plans and set out in detail the action needed to be taken by staff to ensure all aspects of their health, personal and social care needs are met. Develop risk assessments for residents in areas of those susceptible to choking, falls, accessing the community and road safety. Make arrangements to enable those residents who remain at home without any planned activities to engage in local, social, and community activities and for the daily routines of the home to offer more choice. Consult with residents about their social interests and make arrangements to enable them to engage in local, social and community activities. Develop written reactive strategies and carry out risk assessments for those residents who present agitated behaviour in order to support them safely. Ensure all staff receive training DS0000008176.V312065.R01.S.doc Timescale for action 31/03/07 2. OP7 4(b)(c) 31/03/07 3. OP12 16(2)(m) 30/04/07 4. OP12 16(2)(n) 31/03/07 5. OP18 13(4)(b) 28/02/07 6. OP18 13(6) 31/03/07 Page 26 Princess Close Version 5.2 7. OP38 13(3)(c) in the protection of vulnerable adults. Risk assess a residents vulnerability in relation to their access to hot water. 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP30 OP32 Good Practice Recommendations Sign/date documentation in residents care plans in order to monitor changes. Review the training needs of the staff team in order to ensure that staff receive appropriate training to the work they perform. Respond to agreed action plan recommending development of a more open and inclusive environment through a consultative approach. Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 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 Princess Close DS0000008176.V312065.R01.S.doc Version 5.2 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. 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