Inspection on 21/02/06 for 2a Court Road

This inspection was carried out on 21st February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2a Court Road 12/12/08

2a Court Road 30/11/07

2a Court Road 16/11/06

2a Court Road 13/01/05

2a Court Road 10/08/04

2a Court Road 18/02/04

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 2a Court Road Kingswood South Glos BS15 9QB Lead Inspector Odette Coveney Unannounced Inspection 21st February 2006 09:45 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 2a Court Road Address Kingswood South Glos BS15 9QB 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 961 8737 0117 9607195 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Tracy Jean Cunningham Care Home 15 Category(ies) of Learning disability (15) registration, with number of places 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 15 persons aged between 18-64 years with Learning Disabilities 18th July 2005 Date of last inspection Brief Description of the Service: 2a Court Road is located in an established residential area of South Gloucestershire within approximately a quarter a mile of the shopping area of Kingswood where most community facilities exist. Public transport (buses) are available to Bristol City Centre, which is approximately four miles away. The home is purpose built and was opened in 1996. It has three houses within the same building. Two houses have single level accommodation, while the middle house is based on two floors with stairs to the first floor. Each house accommodates five people and consists of individuals’ bedrooms dining room and lounge. Kitchen and bathrooms. There is an activity room and staff administration offices. There is sleeping-in accommodation for staff. The staff team is approximately 38 in total. The home is run by Aspects & Milestones Trust, a voluntary non-profit making organisation. All of the clients previously lived in Stoke Park Hospital and moved to 2a Court Road when it opened in 1996. All of those living within the homes have profound learning difficulties. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided and to monitor standards being maintained at the home in relation to the eleven requirements and the six recommendations from the last inspection that was conducted in July 2005. Staff members on duty, engaging in the inspection process, were informative and interacted well with each other and the clients. The inspector looked around the building and a number of records were examined. What the service does well: What has improved since the last inspection? In order to fully demonstrate that the appropriate actions have been undertaken to ensure the well-being of those living at 2a Court Road the home has informed the CSCI of incidents in which individuals are affected, accident reports contain full information on the actions taken by staff and it is recorded that incidents have been reported to an appropriate person. Staff have received sufficient, appropriate fire safety instruction, this instruction ensures the safety of individuals should a fire occur. Essential Lifestyle and care planning information for individuals living in house 3 have been reviewed and demonstrates that information held is accurate and sufficient and that any changing needs have been identified and met. Information held about risk factors which affect those living at the home has been improved as these documents have been dated and signed in houses 2 and 3 and the manual handling records in house 1 have been dated and signed. The safety and well being of those living in House 3 is now better demonstrated as the safe systems of working are reviewed on a regular basis. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 6 The home has ensured that the privacy for an individual living at house 1 is not being invaded and were able to demonstrate the purpose of the use of a listening monitor. The home has completed a risk assessment on the use of this monitor which is in place to detect noise. The laundering of clothing for individuals at the home has improved and the risk of cross contamination has been decreased as the washing machine in house 1 has been repaired. 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. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Prospective clients to the home can be assured that their needs will be assessed and that the home will meet their needs and aspirations. Contracts were in place between the organisation and those living at the home however information must be added to these documents to ensure that individuals are fully aware of their rights. EVIDENCE: There have not been any new admissions to the home for some time and therefore the process for new admissions was not discussed at this inspection. The contracts in place had been produced by the organisation, and are entitled ‘Licence Agreements’. The contracts seen did not contain information about individual’s financial contributions in order to fund their placement. The agreements had been produced in a pictorial format and included information about an annual increase of which clients would be notified about and any additional costs that individuals’ would be expected to pay such as personal shopping and hairdressing. The contract provided information about insurance of personal possessions, and also details how the home will ensure that individual needs are assessed and reviewed to ensure that services provided are still appropriate. The written and costed statement of terms and conditions between the home and clients were seen held on individual’s files in house two. These documents had not been dated and signed and should be done so where possible by the clients, and/or their representative and the manager of 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 9 the home and it is required that these documents are fully completed for all clients. There are individuals living at the home who do not use spoken language as their main method of communication. Information seen in clients care records clearly showed that staff have established professional caring relationships with individuals and have recorded the complex indicators that clients use such as body language and behaviour, this demonstrates a commitment from the staff team to ensure that the needs of individuals are met. Information seen in care records showed that when specialist advice had been required in order to fully support clients this had been sought; examples of external support included care mangers, consultant psychiatrist and the community learning disabilities team. During the inspection staff were observed interacting with clients, using appropriate language and tone of voice. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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, 8, 9 The healthcare needs of individuals are well met and are reviewed and monitored on a regular basis. Relationships between those living at the home and staff are well established with other needs and choices being met. EVIDENCE: Information held for clients was extremely detailed and it was evident that the information in place had been gathered over a long period of time; all of the client’s records had been written in a person centred way and had been tailored to the specific requirements of individuals. It was clear that information had been gathered through observation of individuals and that their preferred lifestyle had been well documented. Individuals’ personal profiles are in place and contained detailed information such as next of kin information and practical, social, emotional and healthcare support. Care documentation in place also consisted of information that had been tailored to the specific requirements of individuals, such as the reason for their admission and personal history. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 11 Individuals’ had in place an essential lifestyle plan; the information in place within this document covered areas in which individuals require support such as; personal cleaning, dressing, eating/drinking, communication, mobility, providing a safe environment, individuals’ sleep patterns, individual preferences in areas of leisure and social interaction. Each client also had in place a care plan that had identified their personal aims, the plan recorded the action steps that are needed in order to ensure that these aims are met; examples of individuals’ aims included ensuring that an individual is given opportunities to make their own choices in their day to day life, to enable individuals to improve methods of communication for themselves in order increase their levels of self esteem, to maintain regular contact with those important to the person and to support individuals in the manner most appropriate to them. A staff member was asked to give examples of how individuals are able to make choice and to have some control over their lives, they were able to tell the inspector of individual’s decisions, all of which cross referenced with information seen in individuals’ care documents and also what had been observed during the inspection. Individuals were seen to be ‘at home’, were walking freely around the home, individuals were relaxed and at ease in the presence of others. The inspector saw that individuals had risk assessments in place. Each assessment is tailored to the individual and the factors affecting their well being had been considered. All were dated and signed and there was evidence in place to show that assessments are reviewed on a regular basis. Assessments in place included; being supported with aspects of personal care, physical care and medication support. One individual has in place a monitor, which is used at night to ensure a prompt staff response if the individual has an epilepsy seizure. A risk assessment was required at the last inspection, this had been completed and the home was able to demonstrate that its use was for the protection and safety of the individual. The home has developed good strategies for communicating with the clients. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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, 15 Social activities and community presence are well managed, and are tailored to the specific wishes and abilities of the individuals, these were creative and provide daily variation and interest for the people living in the home. EVIDENCE: Information seen by the inspector, and confirmed by staff, and within individuals’ care records showed that those living at the home are offered a variety of social activities. Individuals are able to participate or not, this is dependent on the individual’s choice. On the day of the inspection a number of individuals were out partaking in activities of their choosing, one of the clients was out with a staff member booking their holiday to Wales later in the year. Care plans clearly record what activities individuals enjoy. Daily records and essential lifestyle documents evidenced that individuals have recently enjoyed trips to Bitton railway, music groups, Chew Valley lakes, and other places of local interest. Individuals also benefit from one to one time with their day care 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 13 support worker. Activities within the home include aromatherapy, pampering sessions and massage. Action plans were in place for individuals recording the actions for maintaining family contact and community presence, individuals’ person centred planning documents and review notes outlined how identified choices for social activities and community presence are managed. Each person had activity routines that had been produced in a format most appropriate to them in order that staff can communicate effectively with individuals and encourage choices. Information was in place about people who are important to the client with information recorded on how they will be supported to maintain these relationships. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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 21 Client’s healthcare needs are met including the handling and administration of their medication. EVIDENCE: The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner; evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody and that specialist advice is obtained when needed. It was evident at this inspection that the staff spoken with are sensitive to the emotional, physical and health needs of those living at the home and through observation and discussion demonstrated respect to the wishes of individuals living at the home. There were a number of clients who had no information recorded in respect of their wishes in the event of their death, it is understood that this is a difficult and sensitive subject, however it is recommended that the home seeks and records individuals’ wishes in order that their choices will be respected. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Those living at the home are protected from the potential of abuse and complaints are dealt with appropriately due to staff training and understanding in this area. Staff demonstrated a clear understanding in this area with clear policies and procedures in place. EVIDENCE: The policies and procedures relating to the Protection of Vulnerable Adults were in place. There was good evidence that the Trust systematically ensures that staff are trained to enable them to identify abuse and follow correct procedures for reporting suspected or alleged abuse. A staff member was asked to explain their understanding of the term ‘Vulnerable Adult’, and in respect of their role and responsibility what this meant, this person was able to fully demonstrate their understanding of the term ‘vulnerable’ and what constitutes abuse, examples given were sexual, financial, neglect, abuse of power and physical abuse. Staff training records evidenced that staff have undertaken protection of vulnerable adults training. All clients had in place a copy of the organisation’s complaints procedure and this had been produced in plain language and had incorporated the use of pictures. Due to the communication difficulties of some of the individuals living at the home a staff member was asked to explain how they would know if an individual was not happy or had a concern. The staff member gave clear examples of individuals’ varied methods of communication and said that staff are aware of individuals’ body language, that time would be spent with an individual to ascertain if they were alright. Records of individual’s communication style provide essential information for staff in order to support individuals appropriately. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 16 The registered manager has contacted the Commission for Social Care Inspection to inform of incidents that have affected the wellbeing and safety of those living at the home. In house 2, two clients monies were checked by an inspector and a staff member and it was found that monies held were correct. However, in house 1, staff were observed dealing with clients’ money and were auditing money against individuals’ records. It transpired that one individual’s money was not clearly accounted for. The manager later confirmed what had happened to the individual’s money, a day care support worker had not returned receipts to the home and had not updated the person’s record. It is required that the home must ensure that money held for safekeeping on the behalf of clients must be clearly accounted for and correspond correctly with records held. Inventories seen clearly audited individuals’ personal effects and items of value. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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 The relationships between staff and those living at the home are good, and this creates a warm, supportive, safe environment, which promotes a good quality of life for the individuals living at 2a Court Road. Some improvements are needed in respect of redecoration of areas within the home; and further attention is required in other areas in order to maintain standards and to improve hygiene. EVIDENCE: 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 18 There have been plans for some time that the houses are to be refurbished, to include new kitchens, extensions to the lounge area and also that each house will be entered by its own front door following the elimination of the current link corridor. The proposed building works to all three houses are still on line to be undertaken and has been for some time, however, no date has been set for the work to commence. Not all clients’ private rooms were viewed at this inspection. Rooms seen were warm and comfortable. Each room was well finished with a mixture of furniture supplied by the home and items that clients had bought themselves. Each room was different in its style and the personal effects contained within the room were reflective of the individual’s personal choice, taste and individual need. The Inspector viewed a number of different rooms in each house, There were a number of areas identified during the inspection that require attention in order to ensure that hygiene, safety and privacy of clients is better maintained. House one had a toilet area that requires cleaning of the ceiling and the walls, there is another toilet in house one that requires a seat. It was noted that in the hallway of house one there is a ceiling light cover that is in need of replacing. In house three it was noted that a toilet had a broken lock, it is required that this lock be replaced or repaired in order to ensure the privacy for clients who use this facility. The following recommendations were also made at this inspection: the carpet to be cleaned in the link corridor due to stains that were evident. A number of carpets are badly worn, torn or stained and recommendations were made at the previous inspection that these should be replaced. The manager and staff members spoken with explained that the reasons for the delay in the replacement of the carpets and also why some areas on the home are in need of redecoration is due to the planned refurbishment. The reasoning behind this is understandable however it is evident that the standard of décor within the home has deteriorated. The following recommendations were also made as part of this inspection: In house one the lounge carpet should be replaced, in house three the lounge and the carpet in the entrance hall should be replaced and the lounge and a toilet area should be redecorated a ceiling fan in a toilet area in house three should be cleaned. Two recommendations made at the last inspection, that a source of odour be eliminated and a vent was to be cleaned had been met and were no longer an issue at this inspection. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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): 31, 32, 35 Clients at the home are supported by appropriate staff in respect of numbers, skill mix, and competency. The home ensures that all staff have received sufficient training. However staff training records are in need of review. EVIDENCE: Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. On the day of the inspection the registered manager and an assistant manager were conducting interviews for support worker posts and a number of people were visiting the home in respect of a gardener/handyperson/drivers post for which interviews had been set for Friday 24th February. The inspector saw that the home has developed a protocol for supporting clients to meet interviewees and be part of the recruitment selection process with their views and behaviours being incorporated within the decision making process. Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individual’s and have worked together with 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 20 them and others in order to identify the needs of a resident and then support the person in achieving their goals and future aspirations. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require. A recently appointed member of staff told the inspector about their induction. They said that they undertook a week of corporate induction away from the home that had included manual handling, risk assessment, first aid, fire safety, control of substances hazardous to health and food hygiene. They said that they had been introduced to the mission statement and the values of the organisation and how these would be incorporated within their practice. This staff member also spoke about a conference they had recently attended that had been very motivational to them within their role and how this could be cascaded onto others. At this inspection six staff training files were reviewed, information contained within these showed that staff have undertaken training in areas such as: manual handling, first aid, protection of vulnerable adults, epilepsy awareness and medication competency. From a review of these records for some staff members it was not clear if they had completed an appropriate amount of training. However following consultation with the manager and discussions with staff evidence was produced to demonstrate that sufficient training had been completed. It is recommended that records held should be updated in order to fully reflect training which has been undertaken. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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, 38, 40, 42 The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. Regulation 26 reports must be forwarded to the Commission on a consistent basis. EVIDENCE: Mrs Cunningham has worked in the Trust for a number of years and has extensive experience within the field of learning disabilities. Staff members spoken with said that the manager was approachable and open to new ideas and suggestions. It came across that staff respected the manager and felt that they worked in partnership in order to provide a good service for those living at the home. A requirement was made at the last inspection that the reports of the visits undertaken by a representative of the organisation must be forwarded to the CSCI on a regular basis, the manager had copies of recent visits. Since the previous inspection the inspector has received some reports however the 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 22 Commision has not received copies of these since August 2005 and therefore the requirment will remain and will be reviewed at the next inspection. The inspector saw evidence that the home ensures as far as is reasonably practicable the health, safety and welfare of the client’s and staff. The inspector saw that the home has in place a comprehensive fire risk assessment; this document covered areas of identified risk within the home’s environment. The fire logbook in houses 1 and 3 were examined at this inspection. A requirement was made at the last inspection that staff must undertake sufficient fire safety instruction. Following a review of records held the inspector was satisfied that the home is maintaining regular checks of equipment and that staff are receiving appropriate fire safety instruction. A requirement was made at the last inspection that accident reports must contain full details of what action had been taken and who the accident had been reported to. A review of accident and incident reports during this inspection found that all had been fully reported with appropriate actions being undertaken. The manager has notified the Commission of any incidents that have affected the well being of those living at the home and has demonstrated that incidents had been dealt with effectively ensuring that appropriate actions had been undertaken. A requirement had been made at the last inspection that all risk assessments, including manual handling assessments must be dated and signed. A number of risk assessments were viewed in all three houses during this inspection and these assessments covered areas such as use of medication, road safety and using transport. All assessments were valid and supported individuals to live their life without restriction. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 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 X 2 3 3 X 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 3 26 3 27 2 28 2 29 x 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 2 X 3 X 3 X 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 24 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. 2. 3. 4. 5. 6. Standard YA5 YA30 YA27 YA23 YA27 YA38 Regulation 5(1) b 13(3) 23(2) b 9 (a) 12(4) a 26 Requirement License Agreements must be completed for all clients. The toilet area in house 1 must be cleaned. Toilet seat in house 1 to be fitted. Monies held must correspond with records maintained. House 1 lock to be fitted to toilet door. Reports of the visits undertaken on behalf of the registered provider must be forwarded to the CSCI on a regular basis. Timescale for action 21/04/06 28/02/06 28/02/06 28/02/06 28/03/06 21/02/06 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. 2. 3. 4. Refer to Standard YA28 YA35 YA21 YA28 Good Practice Recommendations Carpet to be cleaned in the link corridor. Staff training records should be updated. The home to seek and record the views of clients wishes in the event of their death. House 1: Light cover in hall to be replaced DS0000003374.V276603.R01.S.doc Version 5.1 Page 25 2a Court Road 5. 6. 7. 8. 9. 10. YA28 YA28 YA28 YA28 YA28 YA30 House House House House House House 1: 3: 3: 3: 3: 3: Lounge carpet to be replaced. Lounge carpet to be replaced. Ceiling fan in toilet area to be cleaned. Lounge to be redecorated. Toilet area to be redecorated. Carpet in entrance hall to be replaced. 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 26 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 2a Court Road DS0000003374.V276603.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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