Inspection on 12/09/07 for 261 Passage Road

This inspection was carried out on 12th September 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

261 Passage Road 10/10/06

261 Passage Road 26/02/06

261 Passage Road 13/09/05

261 Passage Road 01/02/05

261 Passage Road 13/07/04

261 Passage Road 13/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 261 Passage Road Brentry Bristol BS10 7JA Lead Inspector Sandra Jones Key Unannounced Inspection 26th October 2007 09:30 261 Passage Road DS0000026544.V345320.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 261 Passage Road DS0000026544.V345320.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. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 261 Passage Road Address Brentry Bristol BS10 7JA 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 9593223 0117 9699000 www.brandontrust.org The Brandon Trust Mrs Susan Alexandra Massey Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate 1 named person under the age of 40 with physical disabilities until that person leaves the home then the registration reverts May accommodate persons aged from 40 years upwards Date of last inspection 10th October 2006 Brief Description of the Service: 261 Passage Road is operated by the Brandon Trust to provide residential care for up to five residents all of whom are currently female with a learning disability, aged 40 years and over. The home is registered with the Commission for Social Care Inspection. The manager is Mrs Susan Massey who has a wealth of experience supporting residents with learning disabilities and with the current resident group. She is a qualified Learning Disability nurse as is the Deputy Manager, Joyce Montague. This home blends in well with its neighbouring properties and is close to many local community facilities. There is the shopping area of Crow Lane within walking distance; Henleaze and Westbury village are a short car or bus ride away. The home has access to major bus routes and is a short ride away from the Mall Shopping precinct and the facilities it has to offer. The home has the added benefit of a large wellmaintained garden that is accessible to all residents. The garden provides a safe environment in that it is well fenced off and the home is not on a main road. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over one day in October 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Five people live at the home and four people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered through face- to- face discussions. What the service does well: What has improved since the last inspection? 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 261 Passage Road DS0000026544.V345320.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 261 Passage Road DS0000026544.V345320.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is an effective admission process and individuals and to fully enable individuals to make decisions about living the home, information must be more accessible. The Statement of Purpose must be reviewed to make clear the range of needs that can or cannot be met at the home. EVIDENCE: The home’s Statement of Purpose briefly describes the Aims, Objectives and facilities of the home. A review of the Statement of Purpose must be conducted to make clear the range of needs that can or cannot be met at the home. The criteria for admission and, the policies and procedures that enable individuals wishing to live at the home, their relatives and funding agencies to make decisions about moving to the home, must be appended onto the Statement of Purpose. The current format must be assessed to ensure that those people for whom it’s intended can understand it. Each person has a file that includes the Service User Guide, Statement of Purpose, License Agreement and Terms and Conditions of residency. Home’s Service User Guide and License Agreements are symbolised with pictures and words to ensure that individual can understand the documents. One person has moved into the home from another care home and stated that introductory visits took place before moving into the home. The case records of the most recently admitted person was examined and Adult Community Care provided 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 9 needs assessments and community care plans before admission to the home. Members of staff said that one person will be moving out of the home because the home is not able to fulfil the individuals need. 261 Passage Road DS0000026544.V345320.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning system is not sufficiently effective for individuals to benefit from receiving an individualised and consistent service. They can expect to be involved in making decisions about all aspects of their care. Formats must be more accessible for individuals with communication needs. To fully safeguard individuals from abuse protocols and strategies must follow Safeguarding Adults. EVIDENCE: Each person has a Planning for Life File and Intimate Care plans. Personal Plans contain the individuals assessed needs in respect of all aspects of their lives including personal, social, emotional and cognitive care needs. Intimate care plans are then devised from the personal plans. While intimate plans are up to date, personal plans have not been reviewed in over twelve months. The manager said that the review of the personal plans have been delayed because of personal issues with the people at the home. A person centred approach to meeting current needs must be adopted when developing personal 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 11 plans, so that the person is at the centre of their care. Key elements of choice, rights, inclusion and independence must then be used to meet the person care needs to incorporate their likes, dislikes and preferred routines. This will ensure that members of staff meet the individuals assessed needs in a consistent and invidividualised way. The manager said that a keyworker system is in operation at the home and the keyworker role is to support individuals with their appearance, arrange reviews and undertake 1:1’s, to generally be “ the special person” to specific individuals living at the home. A member of staff said that a keyworker is assigned to specific individuals living at the home and they are responsible for coordinating health care appointments, appearance and 1:1’s. One individual living at the home confirmed the role of the keyworker and said that their keyworker is arranging day care service, assists with keeping their bedroom tidy and took to the hairdresser. The manager further stated said that individuals at the home attend their reviews with keyworker, their relatives, outside agencies and advocates. A member of staff on duty said that a member of staff and senior support worker would review the care plans with a keyworker before attending the review meeting. An individual living at the home agreed to give feedback and once prompted by the keyworker, confirmed that they were involved in the care planning process. Advocates were involved with three individuals that recently moved into the home to ensure a smooth transition. One person has communication needs. However, a care plan based on the assessed communication needs of the person is not currently in place. There is a picture book to enable the person to make choices about meals and the manger said that communication profile would be completed by April. The manager has also attended the Mental Capacity Act training and has recognised the need to develop plans regarding the way individuals make decisions. An individual at the home said that daily decisions such as times to rise, retire and activities are made. The staff on duty gave examples of the way individuals are supported to make decisions about all aspects of their care. Restrictions are imposed at the home. The manager said that once one individual moves, the people at the home do not exhibit aggressive and violent behaviour. Three people at times exhibit behaviours that challenge the service and strategies, protocols and risk assessments are in place to guide the staff on the actions to be taken. The manager said that staff have training in Antecedent, Behaviour Consequence (ABC) and specialist training for safeguarding individuals from abuse. Because of the nature of one person’s challenges, staff need support and training to manage these situations. While strategies offer guidance to staff on the 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 12 actions to be taken, strategies and protocols must follow Safeguarding Adults guidance. Risk assessments are completed for activities that may involve an element of risk. Risk assessments are based on community access, mobility and personal care. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are good support systems in place for individuals to lead active and interesting lifestyles and to be valued members of the community. EVIDENCE: Community access form part of the person’s care plans and generally based on community-based activities. The manager said that with the exception of one person, individuals at the home attend day care provision and are in paid employment. During reviews individuals person development is discussed and staff from day care centres are invited to review meetings. The person without day care provision will attend clubs once weekly and will visit shops with the staff at the home, watch TV and read magazines. The manager said that individuals generally relax during weekends and evenings. The individual at the home said that their keyworker is organising day care provision and visits to various day care centres were arranged to assist with making decisions about the day care centre to attend. The staff on duty said that staff take individuals to church so that they can meet their spiritual needs, 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 14 undertake in-house activities that reflect events and festival and visit restaurants. Documentation in place show that individuals at the home use local shops, visit local GP’s and use NHS facilities. The manager said that the needs of the people at the home are being assessed in terms of the home’s transport. The arrangements for visiting the home is specified within the visitor’s book and states that visitors are welcome at all times. This information must be added to the Service User Guide and Statement of Purpose. The manager said that two people have visitors from family and advocates and one person living at the home confirmed that visitors are welcome and can visit in bedrooms for additional privacy. The Service User Guide and Places to Live Agreement are in formats for the people for whom it’s intended. Within the document, the rights of the person and the expectation of both parties are listed and the rules and responsibilities are included within the Service User Guide. The manager confirmed that there is an expectation that individuals participate in household chores with support from the staff. The individual living at the home stated that there is an expectation that they tidy their bedroom, which is done weekly with their keyworker. Feedback was sought from staff about the ways members of staff respect people at the home as individuals. The member of staff on duty said that actively listening to individuals, responding to their questions, handing mail unopened and where necessary, assisting with reading mail and knocking bedroom doors before entering are the ways individuals are respected as individuals. Offering choices such as having a bath or shower, giving individuals time alone n bathroom and toilet also value the person. The manager said that individuals make menu choices at each mealtime. Staff say that individuals are given a choice of two meals and the meal served is then recorded. Records of meals and the range of food kept at the home show that individuals have a varied diet. A record of fridge and freezer temperatures is also maintained. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals at the home have sensitive and prompt support for their personal care needs. Health and Medication needs must form part of the care planning process. EVIDENCE: Intimate care plans are formulated for individuals that have personal hygiene needs and members of staff record the personal care task undertaken. As already mentioned within the body of this report, a person centred approach to meeting needs must be adopted. Aids and equipment were installed to assist individuals to move around the home without staff support. Bath chairs, showers, walking aids and level access ensure the individuals at the home can maintain their levels of independence. The individuals at the home have input from the Community Learning Disabilities Team (CLDT), psychologists and psychiatrists conduct reviews which are convened six monthly or more regularly where necessary. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 16 The manager said that Health Action plans are to be formulated. Individuals are registered with a local GP and staff accompany individual on health car e appointments. Individuals at the home are invited and attend routine screening and one person is a diet controlled diabetic and another is being assessed for diabetes. Records of multiagency visits are kept and show that individuals visit the dentist, optician and chiropodist. The records also show that staff monitor individuals health care needs and where necessary referrals are sought for specialist support. Three people have “When Required” medications and protocols list the triggers and behaviours exhibited which inform staff on administering the medication. A monitored dosage system is used to administer medications and the records cross-referenced with the medications held within the system. A record of medications no longer required at the home is maintained which the pharmacist signs to indicate receipt of the medication for disposal. The pharmacist provides information leaflets. However, medication profiles that specify the purpose of the medication, the side effects and homely remedies not compatible are not currently in place. Medication profiles must form part of the individuals Health Action Plan. Homely remedies are administered when needed from a stock supply and medications administered are recorded separately. However, the records of paracetamol did not cross-reference with the balances held. A member of staff giving feedback said that medication training is provided for staff that administer medication. Individuals at the home said that the staff accompanies them on health care appointments. It was also confirmed that staff provide support with personal care and the level of support provided meets the level of need. The member of staff on duty also said that part of the role of the keyworker is to accompany individuals on health care visits. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaints procedure in place is symbolised with pictures and words and on display in the kitchen. One complaint was received since the last inspection from one person about another living at the home. While the manager said that the complaint was resolved and the person no longer lives at the home, the outcome and level of satisfaction must be recorded. House meetings are other forums used to discuss with individuals concerns about group living. The member of staff giving feedback said that the complaints procedure is followed for complaints from individuals at the home. It was also said that for people with communication needs the pictorial procedure would be used. Policies and procedures that set the approach for Safeguarding Adults from abuse include “No Secrets” and Whistleblowing. The manager said and staff confirmed that Safeguarding Adults training is provided so that they are able to recognise the factors of abuse and can take the correct actions for alleged abuse. The manager said that there were no outstanding Safeguarding Adults referrals. 261 Passage Road DS0000026544.V345320.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): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Individuals live in a comfortable, safe and homely environment that is clean and tidy. EVIDENCE: The property is located within a residential setting and its appearance blends well with the local environment. It was adapted to provide residential care for five individuals with learning disabilities. It is close to shops, local community facilities, restaurants and bus routes. Arranged over two floors with bedrooms on both floors and communal space on the ground floor. There is level access into the home and a chair lift to the first floor ensures that people with mobility needs can move around the home independently. Bedrooms are single and lockable with a combination of the home’s furniture and personal belongings, which reflect the person lifestyle. The bedrooms are decorated to a reasonable standard, with sinks and the appropriate furniture necessary to ensure comfort to meet the individual needs and lifestyles. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 19 The home has two bathrooms with toilets on each floor. On the first floor there is an assisted bath and on the ground floor a shower room is available. The lounge and kitchen are open plan, with a separate dining room. The lounge and dining room has sufficient seating for the group to sit together and socialise or have a meal. The laundry is away from the kitchen on the first floor, it has painted walls and vinyl flooring for easy cleaning. Sluicing facilities, washing machine, with sluicing cycle and tumble dryer are in the laundry, the washing machine has a cycle for sluicing. 261 Passage Road DS0000026544.V345320.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A motivated, competent and effective staff team who are appropriately supervised supports individuals at the home EVIDENCE: Seven staff are employed permanently at the home and the manager said that recruitment files are held at the Trust office. The manager said that there is an expectation that managers check personnel records at the Trust office and an employee’s record checklist of the checks are kept at the home. The manager has checked the references, proof of I.D. and Criminal Records Bureau (CRB) checks for six staff working at the home. The manager explained that the organisation provides 5 days training per year for each member of staff and this year the main focus was statutory and I.T. training. Regarding personal development the manager said that during 1:1 with staff, training needs are discussed. The manager said that statutory training is up to date and consists of First Aid, Food Hygiene, Manual Handling, Fire and Safeguarding Adults. Records of training show that since the last inspection members of staff have attended training courses based on 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 21 Supporting the needs of Older People, Person Centred Care, Understanding Autism, Makaton. Medication and Palliative care. Members of staff are also encouraged to undertake vocational qualification and three staff have NVQ level 2 and two have level 3. The manager said that the two most recent appointments were staff that transferred within the organisation and these staff have completed the Learning Disabilities Award Framework (LDAF) before transferring and an in-house induction. The member of staff on duty confirmed the arrangements in place for staff to maintain their skills to meet the needs of the people living at the home. It was further stated that the training requested is generally provided. 261 Passage Road DS0000026544.V345320.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals live in a safe environment and can be reassured that the standards of care are subject to constant monitoring. EVIDENCE: The manager has a current nurse qualification and has completed NVQ level 4 and the Registered Managers Award (RMA), a vocational qualification. The manager said that a person centred approach and “hands on” style of management is used at the home. Supervision, staff meetings and updating information are the systems in place that maintain the standards of care at the home. The member of staff on duty said that the manager uses an honest, fair and approachable management style, which supports the staff team. It was further said that supervision with senior staff happens monthly and its based on training, problems with staff and work performance. 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 23 The Trust has introduced a Quality Assurance System that annually audits with the staff team and individuals living at the home, the standards of care. The manager said that once the audit is complete the findings are verified by the external manager and sent to the Trust for analysis and the report of the findings is then returned to the home. The manager said that there is an expectation that the home’s annual audit is completed by the end of October 2007. A representative of the Responsible Person visits the home monthly and prepares a report on the conduct of the home, a copy of the report is sent to the manager and the Commission. The rota in place shows that two staff are rostered from 7:30 - 3:30 pm whenever the individuals are at home and during quiet periods staffing levels fall to one member of staff. At night there is one-person sleeping-in. The manager said that permanent and bank staff are used to cover the current 22 vacant hours. Fees are paid directly into the Trust account and range from £813.18- £921.10 per week. The manager said that she acts as appointee for four people currently living at the home. The manager explained that each person has a bank account and cash is withdrawn to cover daily expenses and its kept in safekeeping at the home. Facilities for the safekeeping of cash and valuables exists and records examined cross-referenced with the balances held. There is an expectation that visitors to the home record the date and nature of their visit. Fire Risk assessments are completed and include checking the fire alarm system, emergency lighting, fire fighting equipment and practices for the staff, which entail fire training and fire drills. The manager also ensures that the meets associated legislation by instructing a competent person to check the gas central heating, chair lift and portable appliances annually. An accident book is maintained by the home and since the last inspection and five falls were recorded. 261 Passage Road DS0000026544.V345320.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 2 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 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x 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 2 2 2 x 3 x 2 x x 3 x 261 Passage Road DS0000026544.V345320.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 6 Requirement a) The Statement of Purpose must be reviewed to make clear the range of needs that can or cannot be met at the home. b) Policies and procedure that assist individuals to make decisions about living at the home must be appended onto the Statement of Purpose c) The format must be accessible for the people its intended. A person centred approach must be used to develop personal plans. Individuals likes, dislikes and preferred routines must be incorporated into the action plans. The personal plan for the person with communication needs must include their methods of communication. Formats for people with communication needs must be accessible. Risk assessments, protocols and strategies for people that challenge must follow Safeguarding Adults guidance. DS0000026544.V345320.R01.S.doc Timescale for action 30/01/08 2. YA6 12 (3) 30/03/08 3 YA7 17 (1) (a) Sch.3.l 30/03/08 4 YA9 13 (6) 30/11/07 261 Passage Road Version 5.2 Page 26 5 YA17 17 (1) (a) Sch.3.3m Individuals health care needs and medication profiles must form part of the care planning process. 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 27 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 261 Passage Road DS0000026544.V345320.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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