Inspection on 14/08/06 for 25-27 Teewell Avenue

This inspection was carried out on 14th August 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

25-27 Teewell Avenue 03/07/07

25-27 Teewell Avenue 23/01/06

25-27 Teewell Avenue 10/08/05

25-27 Teewell Avenue 22/02/05

25-27 Teewell Avenue 06/09/04

25-27 Teewell Avenue 18/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOME ADULTS 18-65 25-27 Teewell Avenue Staple Hill South Glos BS16 2NF Lead Inspector Melanie Edwards Key Unannounced Inspection 14 and 21 August 2006 09:30 25-27 Teewell Avenue DS0000003357.V306294.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 25-27 Teewell Avenue DS0000003357.V306294.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. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 25-27 Teewell Avenue Address Staple Hill South Glos BS16 2NF 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 9701573 0117 9699000 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Michael Thurgur Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Old age, not falling within any of places other category (7) 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 5 persons aged 19 years and over with Mental Disorder May accommodate up to 5 persons aged 65 years and over with Mental Disorder 23rd January 2006 Date of last inspection Brief Description of the Service: Aspects and Milestones, a charitable Trust own 26 and 27 Teewell Avenue, Staple Hill. It provides a home for seven adults with a mental disorder who require personal care services only. The houses are semi detached and are interconnecting on the ground floor. There are seven single bedrooms, three in one house and four in the other. The two houses operate as one care home with one manager and a single staff group. The home is situated in the residential area of Staple Hill and nearby there are small local shops, pubs and a church. Further afield, in Downend, there is a library, health centre and more shops. The fees for staying at the Home are from £272 to £334 a week. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four of the residents who live at the Home were consulted during the inspection to find out their views of the service. Time was also spent sitting in the lounge with residents, observing staff carrying out their duties. Two care assistants were consulted about their training needs, and how they assist and support residents. The registered manager Mr Thurger was consulted on the second day of the inspection. A range of records relating to the day-to-day running and management of the Home were inspected. The whole of the environment was viewed both internally and externally. The Home was operating within the required conditions of registration, which are set down by the Commission for Social Care Inspection. The conditions of registration set out the type of care and the needs of residents as well as the numbers of residents who may stay at the Home. What the service does well: What has improved since the last inspection? What they could do better: There must be a controlled drugs cupboard to ensure that controlled drugs can be stored safely in the Home. The carpet in the small lounge should be replaced, as it is marked and stained and becoming worn. The record of food served to residents is insufficiently detailed, currently only a record of evening meals is maintained and there is no written record of residents’ breakfast and lunchtime meal choices. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 6 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. 25-27 Teewell Avenue DS0000003357.V306294.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 25-27 Teewell Avenue DS0000003357.V306294.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): 1,2,3 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Mr Thurger assesses residents’ needs and their needs are well met by the Home. Prospective residents are given the necessary information to help them to make an informed choice about the Home. EVIDENCE: To find out about what type of information is made available for residents and prospective residents about the Home, a copy of the service users guide and the statement of purpose were reviewed. The document included information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs was included. The complaints procedure was also in the document. The guide included information about how care would be reviewed, and the service residents will be provided with. The documents were written in an easy to follow format, and included pictures of the Home. To find out how residents needs are assessed, two residents assessment records were looked at in detail. Mr Thurger had completed a detailed assessment of the physical, mental health and social needs of each resident. There was also information recorded about the resident’s views of their care. Included in the assessments, were the likes and dislikes of the resident, and their preferred choice of social activities. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 9 There was also evidence that the assessments of regular evaluation and updating having been carried out by Mr Thurger and the care staff. This helps to demonstrate residents’ needs are monitored by the Home. To find out how well the Home is meeting residents’ needs two residents care plans were reviewed (see also standard 6). There was detailed information written for each resident clearly stating how to assist individuals with their mental health needs. The staff who were consulted conveyed in discussion and through observations that they had a good understanding of the mental heath needs of the residents. All of the staff were also observed talking to residents in a warm manner. This helps to demonstrate that residents are well supported by staff. 25-27 Teewell Avenue DS0000003357.V306294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ needs are assessed and their care plans reflect how needs are to be met. Residents are well supported to make decisions and to take risks in their daily lives. EVIDENCE: To find out how residents are being supported by staff to meet their needs two care plans were inspected. Mr Thurger had written very detailed information in both care plans. The care plans included information showing how to support, and communicate with the residents and how to assist them with their psychological and physical care needs. The care plans that were seen had been evaluated and up dated on a regular basis by Mr Thurger, which helps to demonstrate residents changing needs are being monitored. Individual files contained relevant letters and assessments from a psychiatrist who will see a resident when required on an outpatient basis at a nearby hospital. There was a physical healthcare needs record in resident’s records. This recorded when the person had last had routine optician, chiropody and 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 11 dental appointments. There was also evidence in each record that they had been consulted and asked their views about the care to be provided. Where a resident had been actively involved in the care planning process this had been recorded. This helps to demonstrate how the Home is trying to take account of residents’ wishes concerning their own care needs. One resident was choosing to have a ‘lie in’ and was still in their room, staff were respecting the residents decision to do this. Residents were also helping themselves to drinks in the dining room. There was also information written in the two residents records that showed staff support the residents to maintain their independence in various daily living activities both in and out of the Home. Residents were observed going for walks to the nearby shops during the inspection. One resident also explained that they went to the shops with another resident `most days’. This demonstrates how residents are supported to make decisions and maintain their own independence in their daily lives. 25-27 Teewell Avenue DS0000003357.V306294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,17 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported and encouraged to take part in a variety of social and therapeutic activities and to be a part of the community. Residents are also provided with a healthy diet although there is a lack of evidence to support what choices residents are offered at breakfast and lunchtime mealtimes. EVIDENCE: 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 13 Residents were asked what social and therapeutic activities they can take part in, and what activities they particularly enjoy. One resident said they had been on a day trip to Bath recently with the support of staff. There are also trips planned to take place soon to areas of local interest that residents have chosen to go to. One resident is shortly going on a golfing holiday with Mr Thurger, which they are clearly looking forward to, as this is their hobby. There was also information written in the two residents records that showed residents go out into the community for social and therapeutic trips. One resident said that they went to local church group every week with another resident at the Home. Another resident said that they walk to the nearby shopping centre on a regular basis. One resident said that they did have family who they regularly see. One resident went out for a walk to the nearby shops during the inspection. To find out what range of meal options residents are being offered a copy of the current menu record, kept in the dining room accessible to residents, was reviewed. There was a range of traditional dishes recorded as being available for each evening meal and residents plan the menu on a weekly basis with the support of staff. However there was no information written on the menus to demonstrate residents’ meal options for breakfasts and lunches. This information is needed to demonstrate that a varied choice of meal options is available for residents. Evening meal options included a range of traditional, nutritional meals. The residents who were asked said the food provided at the Home was `good’, and one resident said the food was of a `first class standard.’ 25-27 Teewell Avenue DS0000003357.V306294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are being supported with their needs in the way preferred by them, and their needs are being met. Residents’ medication is being stored administered and disposed of safely. EVIDENCE: 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 15 There was a record maintained in the two residents care records seen of the physical health needs, and of the residents’ optician, chiropody, dental and GP appointments. This helps to demonstrate that residents’ health care needs are being met. Residents, who wish to be, are involved in care planning meetings with Mr Thurger to review their needs on a regular basis. As also referred to in the report, there was written evidence in the two residents’ care records which showed the preferred day to day routine of the residents and their particular likes and dislikes. This helps to demonstrate how residents are being involved in the planning of their care. The plans of care also stated the preferred manner in which to assist the residents to meet their mental health and social needs. There is the facility for all residents to lock their bedrooms and several residents do this, which provides extra privacy for them. Residents also choose the time they get up and the manner in which they are assisted by staff. This helps to demonstrate how residents exercise choices in their daily lives. Staff were assisting residents in a relaxed manner and residents and staff looked as if they have built up close relationships. The procedures for the administration storage and disposal of medication were checked to monitor if there are safe systems in place. Medication is stored in a locked wall mounted cabinet. However the controlled drug cupboard door is broken, and there needs to be a controlled drugs cupboard facility in the Home so that if required, controlled drugs can be stored safely. The medication administration charts of three residents were read in detail. The charts were legible and up to date, they contained the signature of the dispensing member of staff, and the reasons for any omissions had also been recorded. There was evidence recorded on a selection of residents drug administration charts that random stock checks had been carried out. This helps to demonstrate that residents medication stock is being stored administered and disposed of safely. There were also administration guidelines to assist staff when administering residents’ medication that they only have when occasionally if they are very agitated or distressed in mood. 25-27 Teewell Avenue DS0000003357.V306294.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Mr Thurger and the team listen to residents’ views, and there are systems and training in place to protect them from the risk of abuse or harm. EVIDENCE: The complaints book record was looked at to see how residents complaints are responded to. The complaints book showed that there had been no new complaints recorded since before the last inspection. The record did include the details of how the complaint was dealt with and the outcome. A copy of the procedure for residents to make a complaint is given to all residents and includes the contact details for the Trust and Commission for Social Care Inspection. This gives residents the information they need to complain about the service. All of the residents were asked how they would complain about the Home, and they all said they would speak to Mr Thurger. This shows residents know how to complain if they need to. There is a `protection of vulnerable adults’ procedure to protect residents and to guide and support staff in the event of an allegation of abuse. Staff also said that they had been on recent training on issues related to abuse within the last twelve months. Mr Thurger said that all of the staff team had been able to attend South Gloucestershire Council run `protection of vulnerable adults training, which had been ‘very useful’. This helps to demonstrate how residents are protected form the risk of harm or abuse in the Home. 25-27 Teewell Avenue DS0000003357.V306294.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): 24,25,26,27,28,30 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a Home that is generally suitable for their needs and lifestyles and promotes their independence. However the small lounge carpet should be replaced. EVIDENCE: 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 18 Teewell Avenue consists of two older buildings converted into one property set in a quiet residential area. The Home is close to nearby shops so that residents can access local amenities. All the residents looked to be relaxed and comfortable in their surroundings. Residents’ rooms were personalised with personal possessions. There was furniture and fittings provided, including a wardrobe a comfortable chair a bedside cabinet and a chest of drawers in each room. There were also photographs, and pictures displayed in rooms that helped to create a more ‘personal’ feel to the rooms. One resident showed the inspector their bedroom and said they were` happy’ with it. The bedrooms were satisfactorily clean and tidy. The standard of the decoration and the quality of the fixtures and fittings was satisfactory. Bedrooms do not have en-suite facilities but they do have a sink in them. There were toilets, and shower facilities located within close proximity of the rooms on each floor, which is convenient for residents use. There is a small laundry room on the ground floor. It contains a washing machine and one tumble dryer. Residents use the laundry to wash their own clothes with staff support if needed. This is an example of how residents are supported to maintain some independence in their daily living activities. There is a smoking and a non-smoking lounge for residents. This is for health and safety reasons as several residents do smoke. The smoking lounge and the main lounge were satisfactorily clean on the day of the inspection. The main kitchen is located on the ground floor, leading onto the dining room. The kitchen is a domestic design, and residents use the room to prepare drinks and snacks. There is also a separate kitchen next to the `smoking’ lounge that residents can also use to make drinks and snacks. This helps to demonstrate residents live in a relaxed Home where they can be independent if they wish to be. The kitchen was satisfactorily clean tidy and organised. This demonstrates food is stored and prepared in a safe environment. The Home was clean, tidy and satisfactorily maintained in the majority of areas. However the carpet in the small lounge should be replaced as it is significantly marked and stained and is starting to become worn. 25-27 Teewell Avenue DS0000003357.V306294.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): 32,33,34,35,36 Overall quality in this outcome area is good. This judgements has been made using available evidence including a visit to the service. Residents are supported with their needs by a sufficient number of competent qualified staff who are well supervised in their work. Also recruitment procedures in the Home protect and support residents. EVIDENCE: The care staff on duty discussed recent training that they had attended. Both staff had attended a range of relevant courses within the last twelve months. Both staff said they had attended a range of training that related to the mental health needs of the residents in their care. One member of staff said that they had recently attended a training session on understanding mental health that they had found very useful. There was information on display in the office that demonstrated staff are booked to attend forthcoming training in food hygiene, first aid and fire safety. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 20 The staff duty record for August 2006 was inspected to find out how many staff are on duty to support residents with their needs. There was a small amount of sickness recorded and the Home’s own staff or bank care staff had covered the shortfall in staff. The Home tries to cover shifts with staff who residents know which helps ensure they are given continuity of care. There are at least two staff on duty during the core hours of 10am to 5.30pm, to provide residents with support during the day. There is one member of staff on duty at night who works a waking night duty. There is also an on call support system to support staff and residents out of hours and at weekends. Based on the evidence seen during the inspection, the number of staff on duty is sufficient to meet residents’ needs. The staff observed during the inspection conveyed they were able to communicate and support residents in a sensitive manner. The Trust is in the process of moving staff employment records from the Trust head office to individual Homes. There were some records available in the Home at the time. A sample of staff files were inspected. There are two written professional references taken up for all new staff prior to offering work with the Home. In addition, all staff sign to declare they have not committed a criminal offence prior to employment, as well as completing a Criminal Records Bureau check before commencing employment. These checks are a further safeguard for vulnerable residents. Mr Thurger takes responsibility for supervising the care staff. The supervision records of one member of staff were looked at. It was evident that the staff supervision sessions were based on identified goals, and in how best to support, care, and understand residents and their needs. The staff meetings minutes record was looked at. These showed that staff meetings were recorded as having taken place on a regular basis and staff were consulted about a range of relevant matters related to the day-to-day running of the Home. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Overall quality in this outcome area is good. This judgements has been made using available evidence including a visit to the service. Residents’ benefit from a well run home and are confident that their views are listened to and are a key part of the quality monitoring of the Home. Residents and staff health and safety is being protected. EVIDENCE: 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 22 Residents’ records are kept in a locked metal cabinet in the office. The residents care records, and the records that were seen relating to the running of the Home were satisfactorily written, legible, up to date, and well maintained. This helps to demonstrate residents’ confidentiality is being protected. It also demonstrates Mr Thurger ensures that legal records required for the effective running of the Home are being kept in order. Mr Thurger is a qualified mental health nurse. His career record showed that he has many years of experience working with residents who have a mental health disorder, in a range of settings including Care Homes. He is registered with the Commission for Social Care Inspection as the manager of the Home. This demonstrates Mr Thurger is suitable and qualified to fulfil the role of registered manager. Two residents said that Mr Thurger was, `a very good manager’, and one resident also said that Mr Thurger always listens to them if they have a problem. The two staff on duty also commented that Mr Thurger was supportive and a` good’ manager. A quality-monitoring audit of the care and the service that is provided in the Home is due to be carried out in 2006 by a registered manager of another Aspects Trust Care Home. This will demonstrate that someone with a suitable knowledge of the service has carried out an independent audit of the standards of care in the Home. The monthly monitoring visits of the Home that must be carried out by a representative of Aspect and Milestones Trust are being undertaken as required by law. There are detailed and informative records of these visits being sent to the Commission for Social Care Inspection. The records demonstrate that the designated individual responsible for the visits spends time consulting with residents and their representatives and observing staff carrying out their duties. As has already been referred to in the report one resident said that the senior manager who undertakes these visits spends time with them on a regular basis. The environment looked to be safe and generally satisfactorily maintained. The fire logbook record was checked and showed the required weekly and monthly tests of the fire alarms and the fire fighting equipment were being carried out and were up to date. The kitchen was inspected to see if food is stored and prepared in a safe area. The kitchen was being kept very tidy and organised when seen. Up to date checks of kitchen fridges and freezers are maintained, to ensure they are operating within food safety guidance levels. Staff are provided with regular training in health and safety matters including first aid, food hygiene training and moving and handling practices. This should help protect residents’ health and safety if staff are knowledgeable and well trained in these health and safety principles and practices. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 23 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 3 2 X 3 3 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 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation Requirement Timescale for action 22/08/06 2. YA20 Schedule4.13 The record of food served to residents must include a record of breakfast and lunchtime meal options. 13.(2) The controlled drug cupboard must be repaired or replaced. 21/09/06 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 YA24 Good Practice Recommendations The carpet in the small lounge should be replaced. 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 25 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 25-27 Teewell Avenue DS0000003357.V306294.R01.S.doc Version 5.2 Page 26 - 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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