Inspection on 10/11/05 for 33 Charnhill Crescent

This inspection was carried out on 10th November 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

33 Charnhill Crescent 02/02/07

33 Charnhill Crescent 21/04/05

33 Charnhill Crescent 02/12/04

33 Charnhill Crescent 13/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Charnhill Crescent, 33 Mangotsfield South Glos BS16 9JU Lead Inspector Odette Coveney Announced Inspection 10th November 2005 09:30 X10015.doc Version 1.40 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 Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 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 Older People. 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. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Charnhill Crescent, 33 Address Mangotsfield South Glos BS16 9JU 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 3774018 Aspects and Milestones Trust Ms Janice Griffiths Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4) Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged 19 years and over requiring personal care 21st April 2005 Date of last inspection Brief Description of the Service: Charnhill Crescent is a care home registered with the Commission for Social Care inspection to provide accommodation and personal care to four adults with mental health problems. The home is a detached, corner house in a residential area and has well tended gardens on all sides of the property. The home is a short walk from all local amenities. It is close to a main bus route to Bristol and is also very close to the Avon ring road. The home was originally registered to provide a service for five adults, however some time ago this was reduced to provide a home for three people. A fourth single room is available should it be required. The home has a first floor bathroom and a ground floor shower room with a separate toilet. The kitchen is well equipped and offers space for supporting individuals to maintain their independence. There is a small office area on the ground floor. The home is in good decorative order and well furnished. Those living at the home have chosen the way in which their rooms are decorated. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the four requirements and two recommendations from the last inspection that was conducted in April 2005. Prior to the inspection the inspector received a completed pre inspection questionnaire, which provided information about the establishment, policies and procedures, there was information about those receiving a service at the home. Information was also provided about staffing and visiting professionals. Also prior to the inspection the inspector received six comment cards, one from a general practitioner, two from relatives and three feedback cards from those living at the home. Comments from these have been fed back to the management of the home and have been incorporated within this report. The inspection took place over seven hours. During the process all residents, three staff and both registered managers were spoken with. The inspector looked around some of the building and a number of records were examined. What the service does well: All of the residents at the home told the inspector they were happy. Two residents commented that the home was better now that another resident had left and that the atmosphere at the home was now one of calm. Other comments received from the residents were that ‘ The staff are just like family’. ‘ This has been my home for a long time and there is nothing I would change about it’. All of those living at the home were very much at ease and relaxed, two of the residents showed me their room, one resident showed photographs of their holiday earlier in the year and also showed the artwork they had done of which they were very proud. All of those living at the home spoke with high regard about the care and attention they receive from staff. It was clearly evident that both managers and the staff team are committed to ensuring that all of the needs of individuals at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individuals through a person centred individualised process. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: In order to demonstrate that the holistic needs and wishes of residents in respect of their healthcare, social, and personal assistance are being met and monitored the home must ensure that care plans are reviewed on a monthly basis. The safety of residents and staff would be fully evaluated if the organisation developed a policy on lone working and also if the home undertook a risk assessment in respect of staff that work alone. The residents at the home would be confident that the staff employed receive, appropriate, sufficient training if the home ensured that staff training, including induction were recorded, if all staff received a minimum of three days training per year and also if a new staff member undertook protection of vulnerable adults training. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 7 Those living and working at Charnhill would be assured that complaints are dealt with professionally if these, and outcomes of complaint investigations were recorded. Those living at the home would be assured that staff have in place adequate car insurance cover if evidence of this was in place at the home. Those living at the home would be assured that their property is accounted for if inventory audits were dated. Those living at Charnhill would be confident that their environment were being well maintained if a contractor examined the office window to ensure that damp is not present. 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. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 Information is provided to residents in order that they are aware of their rights and responsibilities. No one is admitted to the home without having their needs assessed and that they have been assured that these will be met. EVIDENCE: Since the last inspection one resident has moved from the home. The individual was admitted earlier this year following a care management assessment, an assessment undertaken by the home and other information provide by specialists. Much consultation and support was provided to the individual prior to their admission and also whilst they were in residence at the home. Following a lengthy period of unsettlement, unfortunately the placement broke down and the person has since moved out of Charnhill. Some discussion took place with management about this and it was felt that the break down of the placement had been unavoidable. The home has kept the Commission informed of the problems being experienced. One of the residents at the home told the inspector that they were sad the person had moved out, but that the home was a much happier place now. There are no immediate plans to fill the vacancy, however when this occurs the manager was able to explain the Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 10 admission process, in line with the organisational policies and procedures that are in place to guide this process. Those living at the home said they were happy and were well supported by staff at the home to live their life and were able to maintain a level of independence. A requirement was made at the previous inspection that terms and conditions must be in place for all of the residents, which are living at the home, and that these must be reviewed to ensure that the information held is correct. At this inspection all three residents had a copy of their licence agreement in place, all of which had been signed by residents to say they were aware of the contents of this document and that this had been explained to them. The contracts had all been reviewed within the last six months. The licence agreement contained clear information for resident’s including information about their fee and what this did and did not include, information was also recorded on staff support and how individuals needs would be reviewed, assessed and monitored on a regular basis, what services were to be provided and also information about house rules. The rules in place are reasonable and fair and had been based on the best interests and safety of all who live at the home. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, Individual’s health, personal, medication and social needs are well met, recorded and reviewed on an ongoing basis. Medication management and recording systems and practice protect residents Support is delivered in a manner to ensure individuals respect and dignity, however care plans must show that they are reviewed. EVIDENCE: There was clear evidence within care records that individuals are supported by staff in order to make decisions about their lives, that they have been given appropriate assistance and that support had been tailored to the needs of the individuals in order that they can make an informed decision. It was clear that individuals had been consulted and their input within assessment processes had been recorded in care records. Each person’s plan sets out in detail the action which needs to be taken by staff to ensure that all aspects of health, personal and social care needs of residents are met, records were seen to be detailed. Staff knowledge on individual’s expectation’s and support was sound however these records do not show that they have been reviewed on a monthly basis and therefore a requirement in respect of this was made. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 12 There was a record of visits to the doctor and other primary healthcare support and these were up to date and sufficiently detailed. The inspector saw correspondence from health professionals, including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required, examples of this includes district nursing services, cancer screening services, chiropody and dentist, demonstrating a ‘multi disciplinary’ approach. Written feedback received from the general practitioner who supports individuals in the home is that the home communicates clearly and works in partnership, that staff demonstrate a clear understanding of the care needs of residents and that they are satisfied with the overall care provided to residents within the home. Medication is administered through a monitored dosage system. The records of administration matched the medication held. A record of medication no longer required is kept. Medication records contained all of the required information in order to direct staff. Medication profiles were in place, which included side effects of medication and indicators of these. One of the residents is supported to maintain their own medication; clear records were maintained of this and the person has a lockable facility in their room in order to keep their medication safe. A notice was in place informing staff of the time period in which medication must be retained in the event of a resident’s death. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 Resident’s lifestyle matches their expectations and preferences and satisfies their social and recreational interests and needs. EVIDENCE: All of those living at the home who were spoken with during the inspection spoke highly enough of the care and attention they receive from staff, one told the inspector that ‘staff listen and spend time with me’, another told the inspector how ‘happy they were that staff help them to go out and shop’. Comment cards completed by those living at the home contained positive feedback about the care and attention they receive at the home indicating that they feel safe and are treated with respect. The inspector received two comment cards from relatives, comments recorded included ‘ I am very happy with the care my mother receives at Charnhill’. At the time of the inspection one of the residents was being visited by a family member, who voiced no concerns and raised no issues over the care of their relative. Other residents told of family members who visit them at the home. The inspector was invited to join the residents for lunch, residents were relaxed and chatting away with each other and staff, one of the residents told Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 14 the inspector about a holiday they had with a family member in a caravan earlier in the year and also showed photographs of their holiday to Paris with a staff member of which they said ‘I had a fantastic time and saw everything I wanted to’. During the inspection one of the residents went out for the morning, another went to the hairdresser and in the afternoon one of the residents went to a local community centre where they said they ‘enjoyed the raffle and bingo and meeting friends’. One of the residents continues to enjoy their work in a charity shop and attending college. During the inspection the staff were busy planning a Christmas party to be held at the home and also were arranging a residents trip to a ‘tinsel and turkey weekend’ later this month. Care records also showed that residents enjoy visitng local shops, pub and library. A staff member told the inspector they enjoyed one to one time with their key resident getting to know them, building a relationship and planning with them on future social events such as the cinema and shopping. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Residents are confident that their complaints would be listened to and taken seriously and staff demonstrated a clear understanding in this area with clear policies and procedures in place, however improvement in complaint and inventory records must be made. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals, this includes a protection of vulnerable adults policy and a ‘Do the right thing’ document. A staff member was asked what their actions would be should they have any concerns over a staff member’s approach and manner, they were very clear on their responsibility to ensure the protection of those within their care and would have no hesitation to report to their line manager. Residents at the home told the inspector they had no complaints and that if they had any concerns they would speak to one of the managers. All of the comment cards completed by residents prior to the inspection confirmed that all of the residents were aware of the complaints procedure and that they knew who to speak with if they had concerns and feedback forms also confirmed that they all felt safe at the home. The inspector saw that there had been a complaint made to the home earlier this year, the information seen showed that the manager had dealt with the situation in a professional and effective manner, the manager confirmed what had happened and what actions had been taken to prevent further reoccurrence and to ensure the satisfaction of the complainant. The home does Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 16 not however have a complaints record book in place, it is required that this is implemented in order that full complaint issues can be recorded with information on the outcome of events, this would demonstrate that situations are being deal with in line with the organisation’s complaints procedure. The inspector saw that all individuals had in place an inventory of their personal effects and belongings and these corresponded with an internal audit undertaken by the Trust earlier this year. Although individual inventories are in place these are not dated to show when items have been audited and only show when the items were purchased and does not demonstrate that these are regularly checked to ensure they are current. It is recommended that these records are dated and signed. The Commission for Social Care Inspection has received notification of incidents that have affected individual’s well being at the home, the information provided shows that individuals had been supported in an appropriate manner. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 25, 26 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 Charnhill. Some improvements have been made in respect of new windows, however one minor area requires attention within the managers office. EVIDENCE: Charnhill is a spacious care home for older people and is furnished to a high standard; the home is a semi detached house and is situated in Mangotsfield and blends in with the local community. Sine the last inspection the home has benefited from three new windows, two in the lounge and one in a resident’s bedroom. It was noted that there appears to be a damp patch within the window area of the office and it is recommended that this be checked by a contractor to ensure that water is not seeping in. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 18 There are a number of toilet, washing and bathing facilities provided at the home that are available for individuals use, these are within close proximity to private accommodation. The number of facilities available are sufficient for the numbers of people accommodated at the home. There is a large lounge with comfortable furnishings, lounge seating at one end with dining facilities at the other. There is a domestic style kitchen and pleasant gardens to the front and rear of the house. Residents were seen making full use of the areas and were very much ‘at home’. Two of the residents showed their room, both of which were pleasantly furnished and decorated and had been personalised to reflect their own tastes and interests. A recommendation was made at the last inspection that the newly admitted resident was to be encouraged to choose the décor for their room, the inspector saw that this room had been decorated with new carpets and curtains and was a nice environment. The home was clean and tidy; staff are to be commended for this as no domestic staff are employed at the home. Residents are supported and encouraged to participate in activities of daily living such as ironing, preparation of drinks and snacks and general tidying. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents at Charnhill are supported by appropriate staff in respect of numbers, skill mix and competency. Staff training should be better recorded and the home must ensure that all staff receive sufficient training. Residents are further protected by the home’s recruitment and selection policy and practices. EVIDENCE: Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 20 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 them and others in order to identify the needs of the resident and then support the person in achieving their goals and future aspirations. There was information in individual care plans these provided information to guide staff to the appropriate level of support that individuals require. The most recently appointed staff member told the inspector that they ‘felt privileged to work here’, ‘it’s so great, I feel very lucky to work here with the ladies’, and ‘they are great’. The same staff member said they had been well supported by the managers and the staff team at the home when they first started, that they were supernumery at first in order that they could learn about the residents and the home. They told the inspector about their induction and about the training they had received. It was noted that their induction had not been recorded, the manager explained that as the individual had been employed for a number of years within the trust it had been agreed by senior management that the full induction programme did not need to be completed. This is accepted however the individual requires an induction tailored to Charnhill and the needs of the residents in respect of their routines, fire safety and the staff members role and responsibilities, it is required that the induction undertaken be recorded in order that it provides information as to what support, information and guidance the staff member has received. Staff files were viewed and training for staff examined, the new staff member said that they receive regular training and feel supported in this area, this person has not received protection of vulnerable adults training and it is required that they undertake this in order that they fully understand this area and what it means to those living at Charnhill. Since the last inspection staff have received training in areas such as health and safety, first aid and ways to manage stress, One staff member has not received sufficient training, it is required that staff undertake a minimum of three days paid training per year. Training records did not also fully reflect the training undertaken by staff, certificates were in place to validate courses completed but training records were not accurate it is recommended that all staff training records are reviewed and updated where required. Those living at the home can be assured that staff employed have been done so following clear and robust recruitment practices and the implementation of organisational policies and procedures. The inspector saw that the home have in place employment documents for staff, these were available and viewed at the inspection, this included references, completed application form a criminal records bureau check and contracts of their employment terms and conditions. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 33, 34, 35, 36, 37, 38 Both of the managers of Charnhill are qualified, skilled and experienced. The management ensure an open and inclusive atmosphere is present in the home, which is run in the best interest of those living at the home. EVIDENCE: Both managers have worked at Charnhill since it opened and knew some of the residents prior to this. Both managers demonstrated a commitment to ensuring that those living at the home were valued, treated as adults with dignity and respect and that they were given options and choices in which to live their lives. Staff meetings are held regularly at the home and cover areas such as individual resident requirements, organisational expectations and staff personal accountability and responsibility. The most recent meeting held in August 2005 covered areas such as resident’s rights, choices, routines of residents and Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 22 professional practice. Staff spoken with felt that meetings were a useful way of communicating and ensuring that all were maintaining standards and quality of life for the residents. Records show that staff receive regular appropriate supervision, supervision that is tailored to individual staff requirements covering appropriate subject matter. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at the home. The folders containing policies and procedures had been revised and re issued in July 2005. Those in place were specific to personnel issues, health and safety and resident specific. Those seen included; admission/discharge procedures, communications, confidentiality, missing persons procedure, complementary therapies, taking risks and post registration education and practice. It was noted that there is a policy on meeting clients alone in their own home when being assessed for a service, however there is no organisational lone working policy, as staff at Charnhill work alone on many occasions including at night. It is d, it is also required that the home complete a risk assessment for this area to encompass and cover all areas of both resident and staff safety. A recommendation was made at the previous inspection that Aspects & Milestones Trust policies and procedures headings must be updated in order to reflect the title of the current organisation. This has been completed and all documents have/or are under review, this recommendation has been found met. All residents money held for safekeeping at the home were accounted for as were individuals taxi tokens, which are issued by the local authority. Staff at the home use their own vehicles to transport residents, there was only a copy of one staff members insurance which confirmed that they are insured to use their car for business purposes. It is required that insurance information be available in order to fully show that residents are protected by insurance cover whilst out with staff. The fire logbook was examined at this inspection; the inspector was satisfied that the home is maintaining regular checks of equipment and that staff are receiving appropriate fire instruction a further fire training session for staff has been arranged for later this month. A comprehensive fire risk assessment was in place and recorded identification of hazard, significant risks and an evaluation of finding, this had been undertaken in May 2005. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 1 Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. 8. Standard OP30 OP38 OP30 OP30 OP7 OP38 OP16 OP36 Regulation 18(1) 13(4) 18(1) 18 15 13(4) 22 13(4) Requirement Induction training must be recorded. A risk assessment to be completed for lone workers. Staff must receive a minimum of three days paid training per year. New staff member must receive protection of vulnerable adults training. Care plans are to be reviewed each month and this is to be recorded. A copy of staff insurance cover to be available for inspection. A record of complaints and outcomes must be maintained at the home. The organisation to develop a lone working policy. Timescale for action 10/12/05 10/12/05 10/05/06 10/04/06 10/11/05 10/02/06 10/12/05 10/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 Page 25 No. 1. 2. 3. Refer to Standard OP18 OP24 OP27 Good Practice Recommendations Resident’s inventories should be dated. Office window to be checked to ensure that it is not letting in water. Staff training records to be updated. Charnhill Crescent, 33 DS0000003358.V265864.R01.S.doc Version 5.0 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. 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