Inspection on 03/05/06 for 3 Trinity Close

This inspection was carried out on 3rd May 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Trinity Close 18/04/07

3 Trinity Close 21/12/05

3 Trinity Close 07/09/05

3 Trinity Close 15/02/05

3 Trinity Close 12/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Trinity Close 3 Trinity Close Bath Bath & N E Somerset BA1 1US Lead Inspector David Smith Key Unannounced Inspection 3 and 22nd May 2006 09:45 rd Trinity Close DS0000008190.V293548.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 Trinity Close DS0000008190.V293548.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. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Trinity Close Address 3 Trinity Close Bath Bath & N E Somerset BA1 1US 01225 443575 01225 443575 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) www.dimensions-uk.org Dimensions (UK) Ltd Mr Paul Flett Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 18 - 65 years requiring personal care only 21st December 2005 Date of last inspection Brief Description of the Service: 3 Trinity Close is registered as a care home operated by Dimensions (UK) Ltd, an independent voluntary organisation, to provide personal care for up to five people who have a learning and physical disability. The home is just a five-minute walk from the centre of Bath, where service users can benefit from ease of access to all the amenities offered within the city. The premises are part of a general needs housing scheme developed by Sanctuary Housing Association. Number 3 Trinity Close is a ground floor flat within a row of what looks like terrace houses. Accommodation is on one level and five single bedrooms are equipped with wash hand basins. Three bedrooms are equipped with ceiling track hoists and closomat toilet. One bathroom has an Aqua Nova bath with hoist and there is an additional shower room with toilet and wash hand basin. There is an enclosed rear patio garden, reached through the patio doors of the lounge/dining/kitchen area. The home has its own leased mini bus enabling service users to access opportunities outside the city centre and the costs are supported by a contribution from service users mobility allowance. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key inspection carried out over two days. The inspector gathered information for this report from discussions with the Registered Manager, three staff members, meeting service users and observing staff communicating with and supporting service users. The inspector examined care plans and associated records, staff training and health and safety records. A tour of the home was also provided. Direct comments from service users are not included as no service users are able to provide these. What the service does well: What has improved since the last inspection? Some areas of the home have been redecorated and some carpets have benefited from cleaning. This helps to ensure a homely environment for service users. All COSHH products kept within the home are now stored securely. This helps to ensure the welfare of service users. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 6 All care plans are now regularly reviewed and a clear record of the review process maintained. This ensures support to service users is consistent with their current needs. The medication administration for service users has been improved. Staff no longer re-dispense medication from the monitored dosage system. 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. Trinity Close DS0000008190.V293548.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 Trinity Close DS0000008190.V293548.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): 1 and 2. The quality in this outcome area is good. Service users are given the information they need about the home to enable them to make an informed choice. Service user support is based on an assessment of their individual needs and goals. EVIDENCE: There is a comprehensive Service User Guide, which has been adapted to include picture symbols. This details the facilities, services and ethos of the home as well as the local structure of the organisation. Service users care needs are assessed prior to entering the service and then translated into their care plan. The two care plans examined showed assessments were carried out prior to service users moving in to the home. There have been no new admissions to the home for some time. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 9 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 and 9. The quality in this outcome area is good. The care plans examined provide good information on supporting each service user. The review process has now been improved. Service users are supported by an experienced staff team, who also advocate for service users where appropriate. Risk Assessments are in place for each service user and are reviewed regularly. This helps service users take risks as part of an independent lifestyle. EVIDENCE: Two care plans were examined. These contained comprehensive support plans for each service user which keyworkers are required to regularly update and organise regular reviews. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 10 The review process has now been improved. In both care plans examined, there were minutes from the last review meeting and clear evidence that Keyworkers had reviewed relevant sections of each person’s care plan. The review meetings had been attended by a representative from the Funding Authority, family members, Keyworkers and the home manager. Discussions between the inspector and the three members of staff on duty demonstrated they had an extremely good knowledge of both the history of service users and their current support needs. Interactions between service users and staff were observed during the course of the inspection. These were conducted in a sensitive and respectful manner. Individual support needs and methods of communication are clearly known and acknowledged by staff. There are Risk Assessments in place for each service user. These are written from a person centred perspective. There remains a clear system of assessment and review in place, which helps to ensure the welfare and safety of each service user. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 11 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): 11, 12, 13, 14, 15 and 17. The quality in this outcome area is adequate. Service users attend specialist day services as well as community-based resources to support their personal development and leisure activities. Service users are supported by staff to use community facilities, enjoy holidays, visits to family and friends and visitors to the home are welcomed. The shortages within the staff team remain. This makes it difficult to provide sufficient support for all service users to enable them to access the community on an individual basis. The home provides service users with a choice of healthy and nutritious meals. EVIDENCE: Service users have their own weekly timetable of activities. These include attendance at specialist day services, hydrotherapy sessions, horse riding, Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 12 Shiatsu sessions, lunches out, walks, trips to the coast as well as activities provided within the home. Each service user has the opportunity to plan and attend a holiday, supported by members of the staff team. One staff member told the inspector that this year a holiday has been arranged in Cornwall during June, which all service users had chosen to attend. One service user was observed spending time both in his bedroom and the lounge listening to music. He made a clear choice regarding the type of music he preferred and communicated this to staff. Another service user chose to go shopping with staff members in Bath. The two other service users were attending their regular day services. One staff member has been recruited recently, however the home does still have a vacancy on the staff team. The existing staff told the inspector they work extra hours to try to cover this vacancy. Service users at times have to be supported in the community together, rather than individually. Service users will sometimes choose this option, and this is respected, but at other times this is solely due to staffing levels. Staff explained that additional staffing is provided one day per week to support the number of activities which occur on this day. On the day of inspection the home had three staff on duty as one staff member’s training session had been cancelled. The staff told the inspector that this level of staffing enabled them to offer more choice in activities for service users. Service users are supported to maintain close contact with families and friends. The home’s policy welcomes visitors at any time. There is a clear record kept within each care plan of family contact, including visits and telephone calls made/received. These records showed that service users receive regular visits from family members. Some service users also stay with their relatives at weekends or during holiday periods. The menus for the last three months were examined. These showed that the home is providing a variety of meals and snacks, which are healthy and nutritious. Service users are given a choice, but staff spoken with confirmed they need to advocate for service users at times. They feel this is appropriate as they have good knowledge of each service user and their likes/dislikes. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 13 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 and 21. The quality in this outcome area is adequate. Service users care plans describe the levels of support they require in relation to their health and social care. This is well monitored by staff and any concerns are acted upon. Experienced staff have a good knowledge of each service user and how to provide the support appropriate to them, however staffing levels remain an issue where service users require the use of a hoist. The medication administration within the home has now improved. Staff no longer re-dispense medication from the monitored dosage system when service users visit their families. The home’s policy regarding ageing, illness and death would ensure service users wishes are respected if such an event were to occur. EVIDENCE: Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 14 The health needs of service users are well met with evidence of good multi agency 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 residents are supported with other primary healthcare needs such as dentistry. Other specialist services are accessed when an identified need arises. These are provided by Bridges Community Learning Disability Team. Care records show the home is regularly supported by the Consultant Psychiatrist, Speech and Language Therapists and other relevant health care professionals. Contact with each professional is recorded and forms part of each persons care plan. Health care appointments/contact are well recorded by staff. Each service user has their own separate file where these records are stored. Staff spoken with confirmed that care plans contained extremely detailed information on the care and support needs of each person. They are also provided with relevant training. Each member of staff commented they felt they had good knowledge of service users’ health care needs and what would alert them to any changes in their health. The continuing needs of two service users dictate that support is required with intimate personal care and hoists are used as part of this process. The care plans and associated Risk Assessments state that two staff assist with the hoisting process. This effectively leaves three service users without direct staff support for short periods of time. This remains unsatisfactory due to the vulnerability of the service users. The home should review staffing levels as previously mentioned in the body of this report. The home uses a monitored dosage system for medication. The administration records showed two staff sign for medication, there is a list of staff names and specimen signatures available, all medication has manufactures profiles in place, stock levels are clearly monitored and recorded and staff have attended training in using the Monitored Dosage system. At the last inspection it was noted that staff were re-dispensing medication when service users visited their families. This practice has now ceased. Staff told the inspector that the complete medication pack dispensed by the pharmacy is now sent with the service user during family visits together with the appropriate administration records. Staff spoken with were unclear on the current policy in administering rectal valium. Not all staff have been trained to administer this and the home still maintains a stock of this medication. This must be clarified to ensure a safe and efficient system is in place for service users. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 15 Care plans contain clear guidance of the action to be taken in the event of the death of a service user. This plan describes the person’s religious beliefs, funeral arrangements, preferred location of the service, requested hymns, donations and nominated charity, memorial and wording and location of the person’s will. These plans have been devised with service users, where possible, and family members. Each person who contributed has also signed this plan. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The quality in this outcome area is good. Service users are supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. Clear policies and procedures are in place in order to protect residents from the likelihood of abuse, neglect and self-harm. EVIDENCE: There have been no complaints recorded since the last inspection. There have been no complaints received by CSCI directly regarding Trinity Close. Each service user has their own complaints procedure, which is kept in their room. Staff members regularly explain this to each service user. Staff spoken with were clear about the advocacy role they have. Due to the vulnerability of some service users, they would rely on staff raising concerns on their behalf. Staff spoken with demonstrated a good knowledge of the action they would take if they suspected or witnessed abuse. They also confirmed that they had received training in the Protection of Vulnerable Adults. They also use their daily interactions and observations when supporting service users to help alert them to any physical signs or changes in behaviour, which may cause them concern. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 17 Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 29 and 30. The quality in this outcome area is poor. Although the home was generally clean and tidy, several improvements must be made to maintain safety, comfort, ensure sufficient space and provide a more homely environment for the service users. Enforcement action will now be considered by the Commission in relation to this continued breach of Regulations. Bedrooms have been personalised by service users with the help of staff. Specialist equipment is provided to ensure service users’ individual needs are met. EVIDENCE: The home was generally clean and tidy on the day of inspection. Staff were observed cleaning communal areas of the home. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 19 The lounge/dining/kitchen area remains the focal point of the home. The lounge/dining area has benefited from redecoration following the last inspection. Some kitchen worktops remain in a poor state and still need replacing. The frontage to one of the kitchen drawers is still missing. Both these issues were identified during the last inspection. The Commission was notified in January 2006, by the organisation, that new kitchen worktops had been ordered and were awaiting fitting. This has not been actioned. Although some have benefited from professional cleaning, several areas of carpeting remain badly stained. Where cleaning has not been effective, these carpets should be replaced. The Commission was notified in January 2006, by the organisation, that carpets in service users bedrooms would be replaced by April 2006. To date they have not been replaced. There has been ingress of water from the property immediately above the home. Staff spoken with told the inspector this occurred during the 2005 Christmas period. Two ceiling tiles are missing and others are badly water stained. Staff were not aware what remedial action is to be taken. This matter had now been outstanding for some months. The flooring in the bathroom is split at the seam near the bath. The edges of the seams are no longer in contact with the floor. This compromises the impermiability of the flooring and presents a significant tripping hazard for both service users and staff. The lock on the toilet door outside the office is broken and the door cannot be locked. This toilet is still used by service users and staff. The inspector discussed the environmental issues with the manager, who explained that these issues have been raised by him consistently with the organisation but still remain unresolved. There is a planned maintenance programme for the home, which should operate on a three-year cycle. This appears insufficient due to the outstanding issues identified in this report and the needs of the people who live in the home. The service should anticipate high levels of wear and tear due to the use of wheelchairs and other equipment. Two service users use wheelchairs and this still presents difficulty in the limited clear space within the home. Staff also commented it was difficult to move the two adapted armchairs easily around the home due to the limited space available and the width of doorways. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 20 Each person has been supported to decorate and furnish their bedroom to make it personal to them. There are also photos and pictures, which help with this process. There is a ceiling track hoist in the bathroom and a mobile hoist is also available. There is a shower that is accessible to wheelchair users. Staff told the inspector that one service user has recently been provided with an adapted chair to enable him to use the shower more effectively and safely. The home also has other specialist equipment to ensure the dignity and comfort is maintained for each person who lives in the home. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36. The quality in this outcome area is adequate. There is a strong core of committed staff who remain focussed on their responsibilities. Staff are well supported by the manager. The relationships between staff and service users are well established. This provides a supportive environment for each individual who lives in the home. Staffing levels need to be reviewed and the home recruit for the vacant staff post to ensure service users are provided with consistent support. Staff are provided with appropriate training and support to ensure they can meet each service user’s care and support needs. EVIDENCE: The home benefits from an experienced staff team. Several members of the team have worked at the home for a number of years and provide consistency and an excellent understanding of service users support needs. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 22 The three staff on duty were confident in their role and helped the inspection process by explaining their knowledge of care plans and policies and providing records necessary for the inspection. Discussions with staff members and observation of their work practice demonstrated that they were approachable, good communicators and were comfortable with the service users living at the home who were at ease with them. Staff members told the inspector that the staff team was open and supportive. They felt supported by the manager and were able to discuss issues in an open and honest way. The home still has one staff vacancy. At present this post is being covered by existing staff working extra hours. Staff spoken with explained that there is little support from the Bank Staff team and they prefer not to use agency staff. The home needs to recruit to fill this vacant post. The home still does not employ waking night staff. There has been a Risk Assessment completed in this respect. It however remains unclear how one service user would summon support from staff during the night if they were in difficulty. Staff meetings are held, recorded and appropriate subjects are discussed in order to guide and direct staff practice. These records show that since May 2005 there have been three staff meetings. The next meeting is scheduled for 22/5/06. This is less than National Minimum Standards expect and staff spoken with would welcome more regular team meetings. Staff are provided with regular, formal supervision. Staff spoken with told the inspector they are supervised approximately every four to six weeks. They said they find supervision helpful and supportive. The training records of four staff were examined. These showed that staff were being provided with all mandatory training together with other appropriate training to enable them to support service users. The home uses a staff-training matrix to track/record staff training. The training provided includes health and safety, fire safety, food hygiene, protection of vulnerable adults, medication, first aid, epilepsy, mental health and autism. Some staff had attended intensive interaction, rectal valium and risk assessment training. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 23 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, 42 and 43. The quality in this outcome area is adequate. The manager is qualified and competent to run Trinity Close, and meet its statement of purpose, aims & objectives. There are policies, procedures and regular checks in place to ensure the health and safety of service users is maintained. All COSHH products are now stored securely. The home has been the subject of a service review. There still needs to be a clear plan of development, together with appropriate timescales to ensure the goals and support needs of service users are promoted. EVIDENCE: The Registered Manager has a degree in housing management and has completed NVQ Level 4 in Care/Registered Managers Award. He also Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 24 undertakes periodic training to maintain his knowledge and update his skills and level of competence. The management approach is open and positive, with a clear sense of direction and leadership. Staff spoken with said their views are listened to, and that they are well supported by the manager. The service review conducted some time ago has not lead to a clear plan of how the service is to be developed and improved. Support staff spoken with still remain unclear if the service will expand by incorporating the space of No.9 Trinity Close, which is immediately next door to No.3 and currently unoccupied, or whether the service will be relocated entirely. They would like to know exactly what is planned for the service. The manager told the inspector that, as far as he is aware, the service still plans to incorporate some of the space in No.9 Trinity Close. This could provide three extra rooms, which could be used by all of the service users. It is hoped one of these rooms would be a sensory room. Extensive building work would need to be carried out to achieve this and there are no plans to carry out this work in the near future. The issues relating to the environment therefore remain unresolved. These are central to the provision of a good quality and accountable service to the people who live at Trinity Close. There are clear recording systems in place to support the Health and Safety within the home. Records examined included fire alarm system checks, fire fighting equipment checks, water temperature checks, servicing of gas appliances, portable appliance testing, servicing of the Aqua bath and hoisting equipment. These checks had been conducted and recorded appropriately. One member of staff present during the inspection is responsible for leading the health and safety within the home. Through discussions with the inspector it was evident she was clear on her role and the responsibilities of this post. Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 25 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 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 1 25 2 26 X 27 1 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 2 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 3 3 3 X X X 3 2 Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES 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 23(2) b Requirement a) Replace the stained corridor carpet, outside the homes shower room [This is a repeated requirement from the last two inspections]. b) Replace dirty carpets in service users bedrooms [This is a repeated requirement from the last inspection]. c) Replace kitchen worktops that are in poor condition. [This is a repeated requirement from the last inspection]. d) Replace carpets in the communal area outside the office [This is a repeated requirement from the last inspection]. e) Repair/replace the flooring in the bathroom. Timescale for action Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 27 f) Repair the lock on the communal toilet door. g) Replace/restore ceiling tiles damaged/stained by ingress of water. 2. YA33 18(1) a 03/07/06 Ensure suitable staff are working at the care home in such numbers to meet the needs of service users at all times. (This is to ensure there are sufficient extra staff to provide activity and also to review and provide waking night staff if it is necessary) [This is a repeated 03/05/06 requirement from the last two inspections]. Review the possibilities to improve the facilities at the home to: increase space; improve ventilation; improve the laundry. Provide CSCI with a copy of the outcome of this review. [This is a repeated requirement from the last inspection]. 03/07/06 3. YA42 23(2) 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 YA19 Good Practice Recommendations Consider development of sensory possibilities to aid stimulation for service users, within 3 Trinity Close, when reviewing care plans. DS0000008190.V293548.R01.S.doc Version 5.1 Page 28 Trinity Close 2. YA24 Review the possibilities to improve the facilities at the home to: increase space; improve ventilation; improve the laundry. Clarify staff administering rectal valium and review the need to maintain a stock of this medication. Consider holding regular team meetings at frequencies which comply with National Minimum Standards. 3. 4. YA20 YA20 Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 29 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 Trinity Close DS0000008190.V293548.R01.S.doc Version 5.1 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!