Inspection on 31/08/07 for 224 Glenfrome Road

This inspection was carried out on 31st August 2007.

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

The inspector found 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

224 Glenfrome Road 13/09/06

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 Unannounced Inspection 31 August & 4 September 2007 09:30 st th 224 Glenfrome Road DS0000026638.V346660.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.V346660.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.V346660.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 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.V346660.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 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. The home 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.V346660.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 key inspection and was carried out over two days. The inspector met 2 of the people using the service, the manager and one of the care team who are regularly involved with their support. There were 11 requirements and 1 recommendation to follow up from the previous visit. There are still some outstanding requirements that have not been met. These must be actioned or further action will be taken. The inspection process included viewing records in relation care and support plans, risk management, the administration of medication, the management of behaviours and interventions, and recruitment and training. A tour of Glenfrome was undertaken with the help of a person using the service. The previous manager Claire Hayward was transferred to another of Freeways homes in January 2007 due to re-structuring within the organisation. Another manager was placed there but left in May. For 3 months there was no formal manager. Ms Debbie Carpenter became Manager in July. What the service does well: What has improved since the last inspection? What they could do better: 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 6 The home must provide suitable information for people through a statement of purpose and service user guide so that they are well informed about the home; any prospective person wishing to move to the home can make a decision through information provided. Up to date contracts must be provided telling people about the services and facilities offered and the terms and conditions of their stay. Assessments and care plans must be in place identifying peoples’ needs and how these are to be met. Peoples’ care, general wellbeing and lifestyle would be better monitored if a daily record was to be kept. Risk management must be improved with clear and detailed risk assessments in place helping to ensure that people are supported safely in taking risks. An individuals behavioural management plans must be reviewed so that staff work in a consistent framework. The home needs to review the management of peoples finances taking into account peoples independent lifestyle and the main aims of the home. The damp on the staircase must be rectified, as does the blackened grouting in the bathroom. A window shelve in a bedroom needs to be repaired and old fencing must be removed from the garden so as to ensure peoples safe access to the garden area. People using the service would benefit from a review of staffing hours linking into the assessed needs of people and how these should be met. The fire procedures must be improved so as to help ensure the health and safety of people. 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. 224 Glenfrome Road DS0000026638.V346660.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.V346660.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5. Quality in this outcome area is poor. The home has no up to date statement of purpose or service user guide that informs people about the home so that they can make a choice about moving to the home. Peoples needs have been assessed but there was little information to identify how individuals’ needs are being met. People have not been given up to date contracts telling them about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no new people admitted to the home since the last inspection. The three people living at the home have lived together for several years. The manager said she has been unable to find a Statement of Purpose and Service User Guide providing information about Glenfrome Road. There was some information seen at the home that partly described the aim of the home, but this was outdated and written when the home was first registered. The manager must produce an up to date document containing relevant and current information; a service user guide must also be available for people informing them of all aspects of the home so that any prospective person visiting the home can make an informed choice whether the home is suitable for them and can meet their needs. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 9 Although the home has carried out comprehensive reviews of two peoples care, there is still sporadic information available as to how staff are to meet their needs. Care files contained a recent assessment for one person that was carried out by their funding placement; another person had a Freeways assessment that had taken place prior to their move to the home, while a third person had both funding placement and Freeways assessment in place. However there was no specific link from the assessments to care plans identifying how peoples’ needs are met. There were two care files that contained an outdated contract and a service user agreement. Since the last random inspection the new manager has improved the management of peoples care files that are currently being kept at Underhay House; the manager is aware that all information concerning the three people living at Glenfrome Road would be better placed in their home for accessibility for both staff and people using the service. 224 Glenfrome Road DS0000026638.V346660.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 Quality in this outcome area is adequate. Although peoples’ care is reviewed comprehensively, there was no evidence to show how the assessment process links into care planning. Some areas of risk management have improved but these still need to be expanded and contain more detail to help ensure people are supported safely in taking risks. People are involved in making decisions about their lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although there was evidence that the home reviews peoples care comprehensively, the manager has been unable to find specific written care plans identifying how peoples’ needs are to be met; a requirement is still unmet for individuals’ assessments and care plans to inform the hours of staffing needed to meet peoples’ needs. The manager is aware that written care plans need to be established urgently informing staff how people should be supported with their care. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 11 The homes review process is a ‘stand alone’ procedure covering all aspects of peoples care including physical and emotional health, vocational, educational and social activities. The home supports a keyworking approach with individuals being supported by named staff. Records identified that the practice of monthly keyworker meetings have not been consistent. This was also the case of daily written records of peoples activities and general well being. One person’s activities had not been recorded for the past 3 months. People would benefit from a record kept so that any changes are monitored and addressed. A person spoken to said they had a recent care plan review with their social worker and the manager. They said that all areas of their care had been discussed and that they had been involved in making decisions about their lifestyle. Another person spoken with showed their ‘Path’ on their bedroom wall that showed their wishes and how these are to be met. They were very clear about how they wanted to live and when they wanted to move on to a more independent environment. They said they also had attended a recent full review of their care. Through discussion with the two people it was indicated that they have a certain amount of autonomy over their lives and are involved in making decisions about their lifestyle. The previous manager had made a start in meeting a requirement to update risk assessments and expand on current risk assessments. These had improved since the last key inspection, but are still in need of more detail and again need to be expanded considering that the three people living at the home are not always supported by staff and aspire to lead a more independent life. 224 Glenfrome Road DS0000026638.V346660.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): 12, 13, 14, 15, 16, & 17. Quality in this outcome area is good. People are involved in leading a more independent lifestyle through their involvement in the routines of the home. They make choices about taking part in meaningful activities both in the home and within the local community. People are supported in having a healthy and varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three people living at the home are involved in activities during the week and access differing independent lifestyles such as work, college courses, and attend day services. All have a front door key and access the community both independently and with staff support. During the visit, two people were observed going to the local shopping area for a coffee. They said that they often visit the local pub and recently went 10 pin bowling and out for a meal to celebrate a birthday. Day trips are offered during weekends and holiday periods with transport available through a mini bus that is based at Underhay House. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 13 One person said they had all been on holiday to Spain supported by two staff. One person explained that they all shared watching different programmes on the television in the lounge, and that they could go to their own rooms for privacy and some space. The sharing of household tasks is discussed at house meetings and all are involved in the routines of the home. People are visited by their family; while others may make arrangements to stay with their family for the weekend. Staff assist in the planning, budgeting and cooking of meals. One of the key times that staff are at the home is during the late afternoon and early evening to support in the cooking of the main meal. An individual explained that people take turns with cooking and if something on the menu chosen was not wanted then an alternative was had. Menus seen identified that meals were both varied and healthy. 224 Glenfrome Road DS0000026638.V346660.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 good. People are supported to lead healthy lifestyles with their healthcare needs being monitored well. People are happy to be supported with the administration medication if needed with safe systems in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: None of the people living at Glenfrome currently need support with their personal care and are independent in areas such as bathing. One person spoken with said they are supported in making healthcare appointments and in going to the doctor. Peoples’ health care files identified referrals to appropriate specialist services are made if needed. Correspondence seen in care files indicated that peoples’ health is monitored appropriately. One person said they had regular meetings with a specialist service who was helpful and supportive to them. It was evident that some areas of peoples lifestyles was dictated by themselves; they chose what time to go to bed and what to wear thereby helping to demonstrate that they are leading an independent life. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 15 Two people self medicate, whilst currently one person is also being supported with taking a temporary prescribed medication. The two people spoken with explained how they took their medication and identified how they kept it safe. The manager showed evidence that she in the process of carrying out risk assessments in relation to people taking medication and that this will include their consent to staff administering medication if needed. One person spoken with said they are happy for staff to support them in this area if needed. All staff receive training in the administration of medication thorough their induction. They then complete a competency questionnaire that is signed off by the manager and sign to agree that they are competent. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. People are confident in making a complaint and feel that they are listened to; they feel safe in their home with processes in place to summon help if needed. People are protected through appropriate staff training. Although the home has written behavioural management plans for an individual these must be reviewed. People would benefit from their finances being kept in their own house. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no recorded complaints since the last inspection. Two people spoken with said they had no complaints and knew the process for making a complaint. One person said that when they had made a complaint in the past this had been followed up with action taken. This has also been identified and followed up at previous inspections. All three people can express themselves openly. However there has been an issue regarding dominance by one person over the others. Although one person spoken with said this had improved with specific action that now takes place to counter bullying tactics, it was observed on two occasions during this visit that this is still an ongoing issue. This concern was discussed with the manager who addressed one of the incidents openly with the two people; during 2 peoples recent care reviews actions had also been put in place for dealing with incidents of bullying It is evident that the manager is aware of the need to review this situation regularly and for people to be able to express their concerns and know that they will be listened to. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 17 Care files identified one person needs support through a behavioural management plan. Through discussion with the manager it was evident that reactive strategies in place must be reviewed due to changes in how their behaviour is now managed. Staffing files identified that 4 staff who frequently work at Glenfrome had undergone up dates in safeguarding adults training. Staff have also previously attended induction sessions at Freeways headquarters covering training in understanding abuse. Discussion was had with the manager concerning the need for people to have access to their monies at Glenfrome Road. Currently peoples money is kept at Underhay House and this practice is limiting in terms of the aim of Glenfrome in providing opportunities for people to be more independent. Two people have said that they wish to move into a more independent housing in the future and will need to have experience of handling their finances to a greater degree. The manager said she is looking at separating the finances of both homes. Emergency on call procedures are in place for people whilst being on their own and unsupported by staff. Both a telephone line through to Underhay House and a Piper Lifeline call system is in place. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 18 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, 26, 27, 28, & 30 Quality in this outcome area is adequate. The home is clean, comfortable and homely and provides a suitable environment for people to live in. However there are still some areas that are in need of maintenance and repair. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glenfrome Road is a semi-detached house based over two floors. There is a large garden to the rear of the property. The house is situated on a busy main road in a residential suburb. It is well in keeping with the local community, and the people living at the home have access to local shops and bus routes. A tour of the home was undertaken; communal areas consist of a small kitchen and lounge. There is one bedroom on the ground floor and two others on the first floor. A bathroom is also on the first floor. All areas of the home were seen barring one person’s bedroom as they were attending their day placement. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 19 There have been problems in the past with damp pervading some areas of the home and although this has been addressed, there is now damp coming through on the staircase that needs addressing. One person showed their bedroom where there had been damp; a staff member said that this had now been rectified. The internal end window shelf in their bedroom needs to be repaired as there an end piece of shelving is missing. The two people spoken with were happy with the decoration of their bedrooms. It was evident that people have made individual choices as to how they wanted their bedrooms decorated. Bedrooms were also personalised with differing effects. Since the last visit there has been no change to the bathroom in that it still requires some attention to remove the blackened grouting; the manager said this has been referred to the maintenance department as a priority. New fencing in the rear garden has been erected ensuring a more secure environment. However the debris from the old fencing needs to be removed. People are responsible for cleaning their own rooms and help with general household tasks. A cleaner is employed in the home once a week to ensure the overall cleanliness of the home. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 20 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, 33, 34, & 35 Quality in this outcome area is adequate. People are supported by competent, trained regular staff; however people would be better supported if staffing hours were reviewed in line with peoples assessed needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota was seen and identified that staffing in place for the day was correct. Although all the staff team at Underhay House could be included in the staffing rota at Glenfrome, staffing at present tends to consist of 4 regular staff who support people for 2 hours in the morning and from 5 to 10 pm. Extra hours are allocated at the weekend. There are no staff who sleep in. The manager is aware that the staffing support at the home needs to be more flexible rather than the fixed rotered hours. This would meet individuals needs better in determining their choices on a daily basis. A senior member of staff spoken with who worked regular shifts at the Glenfrome also said that some of the hours used later at night would be more usefully used earlier in the day. It is evident that people would benefit from a review of the staffing hours provided linking into their care plans and assessed needs. 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 21 People spoken with said they were happy with the support from staff and usually had the same staff they knew which is what they preferred. There was no evidence that staff meetings have taken place; these would take place at Underhay. The manager has begun to set up new staffing files that contain recruitment documentation including Criminal Record checks, application, and references. Four files were seen and had the appropriate information in place. Not all files have photographic evidence in place as yet, however the manager indicated that staff identification was on the computer ready to be processed to update staffing files. Four staff training files were seen. Staff induction includes completing topics through the Learning Disability Award Framework. Staff training records identified that staff have been trained in manual handling, first aid, and understanding abuse. One staff member needs to update their food hygiene certification. Staff have also attended further updates in safeguarding adults and managing challenging behaviour. All records are kept at Underhay House; the manager has improved the accessibility of staff training records and the organisation’s Head office is also centralising this process, with managers, to monitor and ensure that staff are fully trained. 224 Glenfrome Road DS0000026638.V346660.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42 Quality in this outcome area is adequate. The new manager has started the process of updating some areas of the management of the home; this needs to be further developed as does an overall strategy to improve how the aims and objectives of the home are met. Some areas of health and safety must also be monitored better to ensure people are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been employed at both Glenfrome Road and Underhay House for 6 weeks. She has many years of experience in working in this field and displayed a good awareness of her responsibilities under the Care Standards Act. She is aware that she needs to be registered as manager through the Commission for Social Care Inspection. Ms Carpenter demonstrated, through discussion and evidence of changes she has begun to 224 Glenfrome Road DS0000026638.V346660.R01.S.doc Version 5.2 Page 23 implement that she is a competent manager. It was evident that she has concentrated on reorganising information in some areas and setting up new working systems that are easier to access for staff at Underhay House and now needs to progress this to Glenfrome Road. She is aware that she also needs to develop a strategy in fulfilling the aim of Glenfrome to offer further levels of independence for some people. Quality Assurance processes include questionnaires completed by two people recently to get their views on the service provided. The manager explained the process for how information is to be collected and actions to be implemented in the future. Historically the provider monitoring visits to Underhay House include information about Glenfrome. However the home would be better monitored if these visits looked at the homes individually. The Annual Quality Assurance Assessment was not returned to the Commission for Social Care Inspection. It is a legal requirement for this document to be completed on an annual basis. Other members of staff and management are permitted to complete this if there is no registered manager at the home. It must be returned next time or further action will be considered. 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 fire log identified that fire drills have not been carried out on a regular basis and fire equipment checks have been sporadic. The homes fire risk assessment also needs reviewing. The manager must ensure that the home complies with fire safety regulations in helping to protected people and kept them safe. 224 Glenfrome Road DS0000026638.V346660.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 1 2 1 3 2 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 2 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 1 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x 2 x 2 x 1 2 x 224 Glenfrome Road DS0000026638.V346660.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 YA1 Regulation 4 Requirement Produce a Statement of Purpose setting out the aims and objectives of the home, the facilities and services provided. Produce a Service user Guide that contains suitable information informing people about their stay at the home. Ensure there is an assessment of need and care plan in place detailing how people are to be supported and the hours of support required for each person. Outstanding since 01/06/06. Update peoples’ contracts that set out the terms and conditions of their stay. Update risk assessments and expand on current risk assessments. Outstanding 31/01/07 Keep a record of all residents consent to the administration of medication. Outstanding since 30/11/06 Review and update current practice in supporting an DS0000026638.V346660.R01.S.doc Timescale for action 31/12/07 2. YA1 5 31/12/07 3. YA6 15(1) 30/11/07 4. 5. YA5 YA9 5(c) 13 (4) 15 (1) 31/12/07 30/11/07 6. YA20 13 (2) 30/11/07 7. YA23 13 30/11/07 224 Glenfrome Road Version 5.2 Page 26 8. 9. 10. 11. YA24 YA24 YA24 YA42 23(2)(b) 23(b) 23(o) 23(2)(b) individual through specific reactive strategies so that unnecessary risks to their health and safety is identified and so far as possibly eliminated. Rectify the damp area on the staircase. Repair bedroom shelving to ensure areas of the home are kept in a good state of repair. Clear old fencing from garden so that people are safe to use this area. Where the Regulatory Reform (fire safety) Order 2005 applies to the care home the registered person must ensure that the requirements of that Order and any regulations made under it are complied with in respect of the care home. Ensure all staff are involved in regular fire drills at least once in a six-month period. Outstanding since 03/10/06 31/12/07 30/11/07 30/11/07 06/09/07 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. 4. Refer to Standard YA27 YA6 YA23 YA33 Good Practice Recommendations To refurbish the bathroom Keep a daily record of peoples general welfare and activities attended. Review the current practice of keeping monies at Underhay House so that people can be better supported in being independent. Review staffing hours taking into consideration the key times people need support. DS0000026638.V346660.R01.S.doc Version 5.2 Page 27 224 Glenfrome Road 5. YA39 Provider monitoring of Glenfrome to be undertaken separately from Underhay House. 224 Glenfrome Road DS0000026638.V346660.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 224 Glenfrome Road DS0000026638.V346660.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. 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