Inspection on 13/09/06 for 224 Glenfrome Road

This inspection was carried out on 13th September 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

224 Glenfrome Road 31/08/07

224 Glenfrome Road 04/02/06

224 Glenfrome Road 16/08/05

224 Glenfrome Road 27/02/05

224 Glenfrome Road 28/09/04

224 Glenfrome Road 28/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 224 Glenfrome Road Eastville Bristol BS5 6TR Lead Inspector Sarah Webb Key Unannounced Inspection 13 , 15 , 29 September & 2nd Oct 2006 09:00 th th th 224 Glenfrome Road DS0000026638.V310591.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 224 Glenfrome Road DS0000026638.V310591.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. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 224 Glenfrome Road Address Eastville Bristol BS5 6TR 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 9392192 01454 372151 Freeways Trust Ltd Miss Claire Anne Hayward Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 3 persons aged 18 - 64 years of age Date of last inspection 4th February 2006 Brief Description of the Service: 224 Glenfrome Road is registered to provide accommodation and personal care for up to three people with a learning disability aged between 18-64 years. It is operated by Freeways Trust Limited, a charitable trust. The accommodation comprises a semi-detached house based over two floors in a residential area of Bristol. It is close to local shops and facilities. The home aims to provide support for people who are more able to live independently and it is not staffed for a whole twenty-four hour period. Glenfrome has strong links with a sister home, Underhay, which is in walkable distance. Both are staffed by the same team and residents at the home are able to summon help from Underhay in an emergency. 224 Glenfrome Road DS0000026638.V310591.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, conducted over 11.5 hour, with the main focus on checking the progress of the requirements and recommendations from the unannounced visit in February 2006. The home has met five requirements leaving 1 that is partly met. This is in relation to ensuring the home holds appropriate documentation stating an individuals agreeing to their hours of support. During this visit care records and other relevant documents were examined; a resident gave a tour of the home and was actively involved in explaining the routines of the home. Further evidence was gained through discussion with a second resident and a member of staff. Residents were able to demonstrate how to summon assistance in an emergency due to the home not being staffed on a twenty-four hour basis. What the service does well: What has improved since the last inspection? The manager is in the process of developing care plans with health action plans also being implemented. The organisation has developed a quality assurance tool. Risk assessments were in place in relation to being home alone. The home has investigated the noise made by the washing machine; there is some improvement due to repairs undertaken. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 6 The home has taken action to rectify the damp problem. The Gas Safety certificate central heating system has now been serviced. 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. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 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 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to being admitted to the home, and are referred for reassessment if their needs change and the home is no longer able to support them fully. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Residents care files were examined. These included resident’s agreement, organisational assessment, assessment through funding authority, and care plan. It was evident through discussion with the manager and examination of an individual’s care file that their needs have changed and the home has involved other agencies within the Community Learning Disability Team in supporting them. This is seen as good practice and demonstrated a multi-disciplinary approach in supporting the resident. The manager demonstrated that she is proactive in ensuring residents needs are reassessed in order to offer other more suitable placements. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 9 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, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning is in the process of being implemented, as are health action plans. Care plans need to document a change of hours of support. Residents are supported in making decisions and taking calculated risks in all aspects of their lifestyle. EVIDENCE: All three residents have been involved in care planning meetings either through a PATH meeting or Essential Lifestyle Planning. A resident had their PATH on the wall in her bedroom identifying her needs and wishes. The manager has started to produce care plans for residents in order to inform staff of individuals’ needs and how these should be met. She is aware of the need to continue to develop the care planning process and complete all residents’ plans. A review has been planned which will address a requirement to ensure documentation regarding their care reflects a change to their hours of support. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 10 Monthly key worker meetings are held in order to monitor progress and record future wishes and aspirations. A recommendation is made for outdated paperwork to be archived or transferred to another file in order that relevant and ongoing information is easily accessible. Also that appropriate paperwork such as residents reviews are signed and dated. Discussion with residents identified that they make decisions about the way the home is run, and about their lifestyles. This was also evidenced through discussion with staff and individuals care files. Two residents spoken with said they ask staff for advice and support if needed. Risk assessments and discussion with two residents demonstrated that they are encouraged to take risks according to their differing abilities within a risk management practice. Those risk assessments examined included accessing the community, using the kitchen, bathing, and financial dealings. It was evident that a risk assessment had been reviewed due to an incident occurring whilst a resident was cooking and that appropriate support is now in place. However an individuals financial risk assessment is in need of a review. With the home not being staffed over a 24 hour period residents are also supported to take risks in remaining at home alone. A requirement has been met to expand on risk assessing for being home alone. Two residents spoken with were able to demonstrate their awareness of getting support in an emergency. The home has a “piper-line” system that supports them to call for assistance at any time of the day. They were also knowledgeable in how they would contact the emergency services if necessary. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 11 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, 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 encouraged to lead full and active lifestyles and are empowered in being responsible for the care of their home. Their rights are respected and they are encouraged to take responsibility in their daily lives. Residents are supported in making healthy eating options with regard to menu planning. EVIDENCE: Residents access differing independent lifestyles such as work, college courses, and attend day services. They also take part in leisure opportunities regularly either independently, or through accessing other homes within the 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 12 organisation, as a base for activities. Day trips are offered with transport available through a mini bus that is based at Underhay House. All residents are supported to maintain friendships and links in the community. A resident said they had friends at another home that they visited regularly whilst occasional visits are made to Underhay House. A resident said they were planning to visit their family shortly which they were looking forward to. This would be undertaken independently. A resident explained their daily routines, including household tasks, laundry and cooking. Through observation it was evident that staff play a supporting role at Glenfrome, offering advice appropriately. Examination of menus identified that the residents are encouraged to view their food intake through a healthy eating philosophy. A resident spoken with explained how individuals take turns in cooking for each other. If there are some foods that are not wanted by a resident then an alternative is offered. It was evident that the 3 residents know each other well and are aware of any specific preferences. This individual also said that they needed more support with cooking now. A staff member also confirmed additional hours have been allocated to this person. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 13 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, & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead healthy lifestyles with their healthcare needs being monitored well. There were safe systems in place for the administration of medication, however consent needs to be obtained from residents. EVIDENCE: Two residents spoken with explained specific areas that they may need support with in relation to their healthcare needs. These may include routine visits to the doctors, opticians, and dentist. Ultimately they made the choice whether they attended appointments alone or with help from staff. Examination of residents’ healthcare records evidenced that individuals’ physical and mental healthcare needs were being met through regular reviews of medication and advice from appropriate professionals. A resident said they had regular meetings with a specialist service who was helpful and supportive. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 14 A resident has completed their health action plan with the support of a specialist service; this included information about others involved in their healthcare and action for supporting them with their personal support needs, and eating healthily. The home operates a key worker system with monthly key worker reports including health monitoring and developing an action plan. It was evident that other areas of the residents’ lifestyle was dictated by themselves; they chose what time to go to bed and what to wear thereby demonstrating that their service was resident led. The home is informing the Commission for Social Care Inspection of events that affect the well being of the residents in respect of regulation 37. Medication is kept secure. The home holds a small amount of medication on the premises; the arrangements in place were satisfactory and met with appropriate organisational procedures. However there was no documentation stating that residents have consented to medication being administered; therefore a requirement is made for the home to keep a record of consent for all those requiring support with the administration of medication. The home has procedures in place for monitoring staff competency in the administration of medication; new staff initially shadow those deemed competent and are then observed through the medication process. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 15 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be listened to and that they will be protected from abuse. EVIDENCE: The Freeways organisation has a formal complaints procedure; residents have been given an accessible copy of the procedure explaining how people can complain. It also includes appropriate contacts and timescales to respond to any complaint. All complaints are logged and with action and outcome recorded. The two residents spoken with indicated that they knew who they could go to if they had any concerns and complaints. It was evident through observation and discussion with both residents and staff that they also feel confident to express their views or raise concerns either through house meetings or care reviews. A resident said they had made a complaint recently and that the manager was currently investigating this. This is discussed further in Standard 33. The organisation has a policy on the protection of vulnerable adults. All staff are trained in abuse awareness within their induction period. Staff are also trained through local authority courses and by the manager who is a trainer in this area. The issues arising in the home that is viewed as bullying or controlling behaviour continues to be monitored and dealt with sensitively and appropriately by the manager and staff team. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 16 The home has involved other appropriate and relevant agencies in discussing the issues and specialist advice has also been sought. This was evidenced through records of meetings having taken place. The organisation operates safe financial systems for the administration of residents’ finances. This is followed by the home with specific controls in place that are adhered to. During this inspection, a Regulation 26 visit was made by the Principal Care and Development Manager. A copy of the report is sent to the Commission on a quarterly basis. These visits demonstrate that the organisation regularly monitors all aspects of residents care. Residents have a lockable space in which to keep their personal allowances; Excess money is kept at Underhay House for security and only senior management in the home have access to this. A random selection of finances was checked during the inspection at Underhay House. There was a record of all transactions and evidence that personal allowances and benefits were being paid to the individuals. The home operates a safe system for the administration of the finances of the residents. Care files included positive strategies for dealing with challenging behaviour, including triggers and techniques for supporting individuals that also support staff with clear instruction. Staff are trained through both Learning Disability Award Framework and a specific external trainer in recognising triggers in order to defuse situations that may be challenging. Examination of records indicated that the home involves appropriate professionals in supporting both staff and residents. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a comfortable and homely environment. EVIDENCE: Glenfrome Road is a semi–detached house which blends in well with the local community and is close to local shops and bus routes. The home has a sitting room, small kitchen and bedroom on the ground floor. There are two bedrooms on the first floor and a bathroom on the first floor. The home has a large garden to the rear of the property. Since the last inspection a requirement has been met for action to be taken in order to treat damp in the home and the hallway has been painted. Two of the residents’ bedrooms were observed; they were decorated to reflect their individual tastes. One resident said she had recently had some new curtains. Residents have their own keys to both the front door and their bedrooms. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 18 All areas viewed were clean and free from odour. A requirement to take action to reduce the noise level of the washing machine has been met. An investigation into the flooring where the washing machine is placed has been carried out and subsequent work has been implemented. However the home needs to continue to monitor the noise level. The two residents spoken with said they were satisfied with the facilities available within the home. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 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): 32, 33, 34, & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Competent staff support residents, however, the home must ensure the roster reflects a true picture of staff on duty and that those rostered hours are carried out by staff in order to ensure the assessed support needs of individuals are met. The home must ensure there is evidence that a thorough recruitment procedure is being undertaken. EVIDENCE: The home shares the same staff team and manager as Underhay House. An inspection of Underhay House was also carried out during the same date of this visit. Staffing hours for Glenfrome are held on the staff roster held at Underhay House. Staff are flexibly employed at the home at peak times throughout the day. A resident said that this is mainly in the afternoon and early evening when they cook their meals. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 20 Although there is a small core team of staff that support the residents at Glenfrome, it was evident through initial discussion with a resident that there was a recent occassion when a member of staff did not work their rostered hours. As recorded in Standard 22 the resident has registered a complaint with the manager who is in the process of carrying out an investigation. Examination of the roster also indicated that some staff listed to work at Glenfrome are not currently working there. A requirement is made for the home to ensure that the staff roster reflects a true picture of those staff on duty. Discussion with the manager also identified that she will seek to address difficult issues. She organised for a staff questionnaire to be sent out relating to racism. The manager is now addressing issues that were highlighted in the findings. This is good practice. Three staff working at both homes have a National Vocational Qualification Level 3 or a nursing qualification. Once staff complete the Learning Disability Award Framework, they then proceed on to registration for National Vocational Qualification. Currently there are a further three staff who are in the process of completing Level 3 whilst a further two are to commence shortly. The home is working towards meeting 50 of staff having a National Vocational Qualification. The home currently has one vacancy with two staff due to leave shortly. Interviews were taking place during this visit with the involvement of a resident from Glenfrome on the interview panel. This is good practice for residents to be involved in the homes recruitment practice. Six staffing records were examined; these provided evidence that staff are police checked through the Criminal Records Bureau, that staff complete an application form, and two references are sought. Records indicated that two references had been received for staff bar I person where a reference was uncompleted. The home must ensure that if references are deemed unsatisfactory that further references are sought, or provide evidence that they have followed the organisations recruitment policy in order to ensure the protection of residents. Staff records should also include proof of identity through a photograph. Through observation of staff records it was evident that there is an ongoing issue concerning a working visa for a staff member; discussion was had with Freeways who are dealing with this through the appropriate authorities. Training records identified that staff have attended first aid, food hygiene, medication, manual handling and health and safety. Other areas also covered challenging behaviour, mental health, and autism. Induction checklists identified that staff are instructed in day to day, and essential procedures of the home, and house security. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 21 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 22 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): 37, 39, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run so residents can be confident that their rights and welfare will be safeguarded. However, the home needs to improve in some areas of health and safety in order that both resident and staff are kept safe. EVIDENCE: The registered manager, Miss Hayward has run the home for a number of years and has proved herself competent in all aspects of the running of the home. She has numerous qualifications and displays a good awareness of her responsibilities under the Care Standards Act. These include qualifications in NVQ 4 in care and management and an NVQ 3 in training and development. She is also an NVQ Assessor and keeps up to date by attending periodic training. She is the registered manager for Underhay House and Glenfrome Road. 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 23 Staff spoken with stated that all the management team are very approachable with this ethos extending to residents and their families. The organisation has recently produced a quality assurance tool meeting a requirement from the last inspection. This has yet to be implemented; the organisation are to pilot this and receive feedback prior to sending out to all services. The home currently seeks the views of residents through a series of meetings including those at review, key worker and house meetings. Fire training records indicated that annual fire training has been late; discussion with the manager and records evidenced that this will be carried out shortly. The home has smoke detectors and an alarm system. Records also identified that regular fire drills have not been carried out therefore a requirement is made for this to be implemented in order to ensure the safety of residents and staff. The fire risk assessment is also in need of being updated. Records indicated that fire equipment is checked on a weekly basis. Examination of documentation evidenced that a requirement has been met to ensure the gas central heating system has been serviced in the last year. The home has generic risk assessments relating to health and safety aspects and follows instruction through the control of substances hazardous to health in holding safety data sheets identifying risks. Day files record residents’ welfare and daily activities and communication between staff was seen through diaries; all confidential records are stored appropriately. Those records seen have been recorded previously in the text of the appropriate standard apart from a requirement to update residents’ inventories. The home has a current certificate of public liability insurance. 224 Glenfrome Road DS0000026638.V310591.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 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 2 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x 2 2 x 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1) Requirement Ensure there is an assessment of need and care plan in place for an individual agreeing to their hours of support. (Carried forward) Timescale for action 31/12/06 2. 3. 4. YA9 YA20 YA34 13 13 (4) Sched 4.6 Update risk assessments Keep a record of all residents consent to the administration of medication. Ensure that if references are deemed unsatisfactory that further references are sought, or provide evidence that the organisations recruitment policy is followed. Staff records to include proof of photographic identification. Ensure that the staff roster reflects a true picture of those staff on duty. Ensure all staff are involved in regular fire drills. Update fire risk assessment. Update residents inventories 31/01/07 30/11/06 03/10/06 5. 6. 7. 8. YA34 YA33 YA42 YA41 Sched4.6 Sched 4.7 23(2)(b) Sched 4.10 03/10/06 03/10/06 03/10/06 31/12/06 224 Glenfrome Road DS0000026638.V310591.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA41 Good Practice Recommendations 1) Archive outdated paperwork or transfer to another file in order that relevant and ongoing information is easily accessible. (2) Sign and date appropriate paperwork such as residents reviews. 224 Glenfrome Road DS0000026638.V310591.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 224 Glenfrome Road DS0000026638.V310591.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. 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. 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