Inspection on 30/11/07 for 2a Court Road

This inspection was carried out on 30th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 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 16/11/06

2a Court Road 21/02/06

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 Key Unannounced Inspection 30th November 2007 09:00 2a Court Road DS0000003374.V352001.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 2a Court Road DS0000003374.V352001.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. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 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.V352001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 15 persons aged between 18-64 years with Learning Disabilities 16th November 2006 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) is 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 is registered to accommodate five people and consists of individuals’ bedrooms dining room and lounge. Kitchen and bathrooms. There are staff administration offices and sleeping-in accommodation for staff. The staff team is approximately 38 in total. Aspects & Milestones Trust, a voluntary non-profit making organisation, runs the home. 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.V352001.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was part of a key (main) inspection and took place over two days, by one inspector. The first visit to the service took place on 30th November at 7.00pm; this was to spend time with those who live at the home. The second visit took place on 7th December and the purpose of this visit was to focus on the requirements and recommendations made at the last key visit to the service, which took place on 16th November 2006, and a random site visit that was undertaken on May 16th 2007. Requirements and recommendations made at these visits were reviewed, as were the key standards as identified by the Commission. Prior to the inspection an Annual Quality Assurance Assessment had been completed which allows the Registered Manager to describe what the home does well, what has improved over the past 12 months and the areas for improvement that have been identified. This assessment was comprehensively completed and provided clear information about the home and the future development plans and areas raised within this document were verified during the visit. A number of comment cards were received prior to the site visit, five were from relatives of those living at the home and five were from health and social care professionals, comments within these were reviewed during the site visit and were shared with the manager, maintaining confidentiality. Some of the comments raised are included within the main body of this report. It was evident that there have been efforts made to improve some of the areas identified at previous inspection visits. The management team and staff were very helpful during this visit, and receptive to suggestions which is an indicator of the commitment from the staff team to provide a good service for those living at 2a Court Road. What the service does well: The service provided at 2a Court Road is good and those living at the home have complex needs. Staff are skilled at supporting individuals on an individualised basis, staff ensure that individual’s are given choices and are empowered to make decisions that will affect their life. The home has identified the essential lifestyle choices of individuals who live at 2a Court Road and strive to achieve these. Care planning information is well recorded and provides clear direction for staff as to how individuals wish to be supported. The home liaises well with outside agencies and other professionals in order to ensure that those who use services are supported in all areas of their life including health, emotional wellbeing, leisure and social activities. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 2a Court Road DS0000003374.V352001.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 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to use the service and their families are given good information in written or verbal form about the home. They know if the home can meet their needs before moving into the home. Licence Agreements/Terms and Conditions of services contain all of the required information. EVIDENCE: The statement of purpose was fully reviewed during the last site visit to the service and this document was found to contain all of the required information needed for individuals to make an informed choice about the service, which can be provided. The home is currently in the process of reviewing and updating the service users guide; the one for house two was reviewed. This guide was well written and enhanced by the use of photographs and pictures. Included within the guide was a copy of the home’s statement of purpose, a description of the house, information on how individuals would be supported in various aspects of their life, how their confidentiality would be maintained and how they would be supported to maintain relationships which were important to them. The 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 9 document included the seven outcomes of the governments ‘Our Health, Our Care, Our Say’ which provides direction for community services; outcomes include improving the quality of life for those who use the service, making a positive contribution and improved health and emotional wellbeing; the document provided real examples of how these would be achieved for individuals. All the people have standard Trust terms and conditions and licence agreements in their case files. These contain all of the required information. The staff have read the provisions to individuals. There are a diverse range of needs and abilities amongst the people who live there. The home employs some Registered Nurses (RLDN’s) who have knowledge and experience in relation to both learning disabilities and mental health needs. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People continue to be involved with the assessment and care planning/goal setting and review process as much as they are willing and able. The home’s philosophy promotes each person’s individual development and self-direction and empowerment. EVIDENCE: The care documentation written about those who live at 2a Court Road is well written. It is clearly evident that care plans have been developed with, and owned by, the individual, based on a full and up to date holistic assessment. The care plans seen are person centred and focus on the individual’s strengths and personal preferences. The care plans seen record individual’s life experiences and set out in detail how all their current requirements and aspirations are met through positive individualised support. The manager and staff said that key workers are currently working with individuals to make DVD’s with them about themselves, their interests, their likes, dislikes and 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 11 what is important. The inspector looks forward to reviewing progress in this area at the next visit to the service. Care and associated documentation showed that all people are treated as individuals with differing wishes and choices, individuals cultural diversity is also well respected and supported at the home with one individual having specialist hair care products for afro Caribbean hair and them being escorted to a black Africa history event. During the site visit undertaken in November 2006 a recommendation was made that consideration should be given to the use of language and terminology within written daily records, a random sampling of daily records were viewed in all three houses and all were found to contain clear factual, non judgemental information. Care documentation including risk assessments, essential lifestyle documents, and person centred planning and communication strategies. During a site visit to 2a Court Road on 16th May 2007 following a review of a service users records two requirements were made, one was that care plans must contain full information to record why decisions have been reached on behalf of individuals and the other requirement was that a risk assessment to be reviewed re; support timings for an individual should they fall in the shower. It was found during this visit that the home have worked diligently to ensure that the rights of individuals who are unable to advocate on their own behalf are respected and risk assessments are clear. Following training in respect of the Mental Capacity Act the home has sought advice from an independent mental health advocacy service The attitude and approach of the staff team promoted independence and supported people, where able, to make decisions about lifestyles and daily routines. Each person was offered the support of a named key worker, a member of the staff team with specific responsibilities towards supporting the person to identify what was important to them, such as relationships with others in the house, and leisure activities, and who also supported issues that caused them anxiety or which they found difficult to deal with. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have opportunities to take part in a range of community and leisure activities. The recreational and occupational arrangements in the home are well organised, individualised and varied. The menus are varied, offer balanced diet and include individual choice. EVIDENCE: The level of activities has been maintained for those individuals who enjoy active lifestyles. These are meaningful and on the whole are chosen by the individual. People continue to go out to make use of community leisure facilities such as pubs, walking, swimming, bowling, discos and shopping for personal items. Various day trips and short breaks are also arranged based on individual’s choices. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 13 Care plans and risk assessments are in place, which detail weekly activities. There are people who attend local churches periodically. Individuals are helped to maintain links outside the home with family and friends. There are some strong family links in place and many have some level of contact with their relatives, which include home visits for some. Some relatives are involved with care reviews. Menus continue to be devised on a regular rotational basis and these can be adapted and are flexible to meet the choices of individuals. During the visit individuals in house one were seen enjoying their lunch with three different meals being offered. Some individuals go shopping with staff and choose food whilst out. The records show that people eat a balanced diet with a good variety of meals on offer. Staff have also attended ‘Healthy Eating’ training in order to support individuals with this area of their lives. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff provide appropriate personal support care in a sensitive manner to maintain each persons health and well being. Appropriate arrangements are in place for individuals to access primary and specialist healthcare services if needed. Generally, staff properly manage and administer medication. EVIDENCE: During the site visit to the home undertaken in November 2006 a requirement was made that those working at the home must respect the privacy and dignity of service users. Staff, at all times, during both visits were found to be respectful and polite with no concerns about individual’s privacy or dignity being compromised noted. Records were also found to be written in a person centred way with the rights and choices of individuals being paramount. A requirement was made at a previous site visit to the service that when a health need has been identified the home must respond appropriately to ensure needs are being met, A review of individuals health action plans, daily 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 15 records and all associated care planning documents found that issues are dealt with promptly and specialist services are contacted and needs are well met. Examples seen included; support from a dietician, support in attending hospital appointments and medication and emotional wellbeing being well monitored as well as individuals physical needs. Evidence was recorded that people had been supported to see their GP, dentist and optician. Incidents of inappropriate behaviour as a result of a person’s anxiety were documented and monitored by the assistant homes managers who in turn feed this information to the Registered Manager, to identify if further support and guidance is necessary to overcome these difficulties. These records were clear and gave consideration to the events leading up to the incident and the consequences of the behaviour. People are supported by other healthcare professionals such as nurses, psychologists and psychiatrists Systems of medication were reviewed in house two and processes here were found to be robust with clear and accurate records being well maintained, however, a review of medication administration and recording in house three revealed a number of errors. These included stock medication and routine prescribed medication not being accounted for and excess medication that had not been returned to the pharmacist for disposal, it is required that records of medication administration are better maintained in this house to ensure the safety and protection of those who use the service. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has appropriate measures in place in order to adequately protect individuals from abuse. There are good arrangements in place for staff training and awareness of protection of vulnerable adult issues. EVIDENCE: Aspects and Milestones continue to have an established complaints procedure that details actions taken if concerns are raised, within set down timescales. All the people living at the home have access to a copy of the organisation’s complaints procedures, which include the contact details of the Commission and of the Trust officers. It was further noted that one of the individuals living at the home has been supported to make a formal complaint and this was responded to appropriately. 2a Court Road accommodates a number of people who display complex and sometimes challenging behaviour and there is a “ Behavioural Risk Management policy” in place. This outlined trigger points, which may lead to challenging behaviour, escalation points and strategies to reduce the likelihood of this occurring. There is a pictorial version of the complaint procedure. It is unlikely that individuals could or would make use of formal procedures and in general would rely upon staff or other significant people advocating on their behalf. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 17 The home has clear and robust adult protection protocols, policies and procedures in place. These include a staff ‘whistle blowing’ document and South Gloucestershire Social Services Protection of Vulnerable Adults Policy. The Local Authority has recently updated its policy and this is now called ‘Safe Guarding Adults’. It is recommended that the home obtain an updated version of this document. There is a policy titled “Doing the right thing” which encourages staff to report bad practice without fear of being discriminated against. There are staff working at the home that have either achieved or are undertaking a National Vocational Qualification in Care, (Health and Social Care, Level 3) and this has a core unit that incorporates adult protection and staff responsibility should they have any suspicions or concerns. It was further noted when reviewing staff training files that staff have completed training in the protection of vulnerable adults. 2a Court Road accommodate some people who display complex and sometimes challenging behaviour and there is appropriate individualised risk asesments and processes in place to support individuals, these also outline trigger points, which may lead to challenging behaviour, escalation points and strategies to reduce the likelihood of this occurring. Aspects and Milestones have a robust and established recruitment procedure. CRB /POVA and NMC checks are carried out by the personnel department. The trust has a satisfactory induction and orientation programme, staff work through an induction process prior to completing NVQ level 3. Records of such are kept. A detailed in-house induction programme has also been produced. The majority of the support staff have now commenced or are part way through NVQ level 3 courses. There are well recorded and sound staff supervision and appraisal processes in place. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29, 30. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. The home has not met requirements in respect of flooring that have been outstanding for sometime. EVIDENCE: At the key site visit undertaken on 23rd November 2006 a requirement was made for the Trust to forward confirmation of when the refurbishment works are to commence at the home. A letter was received by the commission outlining the proposals for refurbishment however work has not commenced with no definitive date being set. During the random site visit to the home undertaken in May 2007 it was noted that the toilet area within house 3 has been redecorated and the kitchen in house 1 had been refurbished, however, the recommendations made at the last inspection in respect of the carpets that needed to replaced in houses 1 & 3 had not been met. At the visit in May 2007 the manager Tracy Cunningham said that the reason they have not been replaced was due to the impending building works due to take place, sometime within this next financial year. After the visit the Trust were requested to provide confirmation of a date when 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 19 it is anticipated that the work will commence, this was received and the response at that time was deemed to be satisfactory. It should also be noted that there have been proposals for improvement to the houses for sometime; these have been reported within previous inspection reports since August 2004. Due to the delay in these issues being addressed it was required through Regulation 23(2) (b) that: ‘The premises are kept in a good state of repair’, this incorporates the outstanding recommendations made at the inspection undertaken in November 2006. Requirements made during the visit in May 2007 were; • • • House 1: Lounge carpet to be replaced. House 3: Lounge carpet to be replaced. The Trust to ensure that the home is well maintained for those individuals who live there. There was evidence to show that the home has been redecorated in a number of areas and this has been undertaken by a staff member employed at the home. However neither lounge carpet has been replaced with further deterioration noted in other areas of flooring. In house one there is a tear in the vinyl flooring in the laundry area with the potential for this not to only be a trip hazard but also a source of hygiene and infection control. Furthermore the kitchen flooring in house two is dangerous and should be replaced immediately the gaping hole in this flooring is a risk to all of those who use this area. It should be noted that an environmental health officer visited the home on 28th September 2007 and an overall five star rating was given for standards maintained within the three kitchens. Written feedback obtained from a health professional recorded; ‘The environment is not ideal but this is an inherited issue and I understand that Western Challenge is due to spend money on the building, from my occupational therapist perspective baths/showers and bathrooms need to be prioritised to meet long term needs’. Discussion took place with the manager about this who agrees that individuals have changing needs and where the home is able to they adapt to meet these needs. The shower in house two has been completed and the home has a hi/low bath for those with mobility difficulties. It was clear from discussions with staff that some are frustrated that work to improve the building for those who live there has not commenced with many time targets being set yet never reached. It is proposed that the Commission meet with representatives of the Trust in order to look at the proposals for development in particular the timescales allocated and the impact on those who use the service. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust. Staff are enthusiastic, have a good understanding of the peoples’ needs and work positively to improve their quality of life. EVIDENCE: Previous visits have reviewed the recruitment and selection processes that have demonstrated a robust procedure is in place. All the required information was available, including Criminal Record Bureau checks and 2 written references, ensuring as far as possible only suitable staff are employed. Regular staff meetings and individual supervision sessions take place and addressed the principles and values of the Organisation, staff performance and training and development needs, as well as day-to-day support issues. Staff were observed throughout the inspection to interact with the people living in the home and each other in an informal, friendly and respectful manner. A sample of staff training files were examined, including one for a newly appointed staff member, information seen showed that staff have undertaken 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 21 core skills training such as fire safety, manual handling, first aid as well as specialist training when required such as; dementia awareness, record keeping and competency assessment. The trust has a satisfactory induction and orientation programme, staff work through the comprehensive Trusts induction process prior to completing NVQ level 3. Records of such are kept. A detailed in-house induction programme is also in place. The majority of the support staff have now commenced or are part way through NVQ level 3 courses. The staff supervision and appraisal process is in place. There are regular team and management review meetings meetings in order to ensure effective service delivery, continuity of service and effective communication. The inspector spoke individually with a staff member who said they are very happy within their role at the home and said that they felt well supported both by the management and the organisation, this member of staff knew who to speak with if they were unhappy. This member of staff was fully conversant with the in depth and complex nature of the support that individuals require at the home and gave sound examples of how individuals are given choices and how their rights are promoted and how individuals are treated as adults. Written feedback received from relatives of individuals who live at the home included; ‘it appears as if individuals needs are fully catered for, and great care for them is provided’, ‘The home understands and cares for my relative they are always there for them and meet their needs well’. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is clear leadership and a strong focus on the outcome for service users in all management and development decisions. Peoples’ rights, health, safety and welfare are protected and promoted. However recording of fire checks in House one must be improved. EVIDENCE: The Registered Manager is well qualified, holding a National Vocational Qualification at level 4 in Care and the Registered Manager’s Award. Ms Cunningham is well able to demonstrate her knowledge and skills in managing a care home and supporting people with complex support needs. She has had many years experience in working for the organisation, and has been the manager of the home since 1991. 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 23 A representative of the Registered Provider for the Organisation had visited the home each month. These visits are used to ensure the home is being managed within the Organisation’s policies and procedures and included reviewing areas such as each person’s support plan; whether there have been any incidents where a person’s behaviour has placed either them or another person at risk; the homes’ financial records as well as those monies being held for safe keeping; issues relating to the management of the home and staff training and supervision. A report of these visits had been sent regularly to the Commission. Prior to the site visit the Commission received from the Registered Manager a completed annual quality assurance assessment. The annual quality assurance assessment (AQAA), is a new process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the Registered Manager was fully completed and detailed Written feedback received prior to the visit to the service recorded; ‘I have found Tracy Cunningham very approachable and friendly, she is enthusiastic whilst doing a tough job’. Another health professional commented; ‘I am impressed that the manger recognises and deals with difficulties which arise from time to time, she does this with sensitivity and empathy for the staff member yet does not fail to address issues’. The fire safety logbooks were reviewed for all three houses, houses two and three demonstrated that full and sufficient checks in respect of all areas were being undertaken. However this was not the case in house one, where weekly, monthly and daily checks were not recorded it is required that this is undertaken in order to ensure safe practices and procedures are in place for the safety and protection of all. It should be noted that all staff have received sufficient fire safety instruction. The home displays a current certificate of Employer’s Liability Insurance. Both internal and independent external audits of financial records and proceedures take place and no irregularities have been identified. Individual’s finances are well audited at the home; the home has clear information to show that the registered manager is acting as an appointee, supporting some individuals with their finances. 2a Court Road DS0000003374.V352001.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 3 2 3 3 X 4 X 5 3 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 1 25 X 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 3 2a Court Road DS0000003374.V352001.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 YA24 Regulation 16 (2) (c) Requirement House 1: Lounge carpet to be replaced. (Outstanding since November 2006). House 3: Lounge carpet to be replaced. (Outstanding since November 2006). To ensure that the home is well maintained for those individuals who live there. House 2: Kitchen flooring to be replaced. House 1: Flooring in the laundry area to be replaced or made safe. House 3: Recording of medication must be improved. Record keeping of fire safety checks in House 1 must be improved. Timescale for action 20/02/08 2. YA24 16 (2) (c) 20/02/08 3. YA24 23 (2) (b) 20/03/08 4. 5. YA24 YA24 16 (2) (c) 16 (2) (c) 20/02/08 20/02/08 6. 7. YA20 YA42 13 (2) 17 (2) 20/12/07 20/12/07 2a Court Road DS0000003374.V352001.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations The home should obtain a copy of the South Gloucestershire’ safe guarding adults policy. 2a Court Road DS0000003374.V352001.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. 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