Inspection on 02/02/07 for 33 Charnhill Crescent

This inspection was carried out on 2nd February 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 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 10/11/05

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 Key Unannounced Inspection 2nd & 5th February 2007 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 DS0000003358.V328219.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 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. DS0000003358.V328219.R01.S.doc Version 5.2 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 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Joanne Ruth Bewley 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) DS0000003358.V328219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged 19 years and over requiring personal care 10th November 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. DS0000003358.V328219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the manager on duty. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for all of the individuals were reviewed. All residents, the registered manager and staff on duty were also spoken with. What the service does well: What has improved since the last inspection? DS0000003358.V328219.R01.S.doc Version 5.2 Page 6 The home had met seven of the eight requirements made at the previous inspection. All living at the home can be assured that their plan of care is monitored as evidence was seen to demonstrate that these are reviewed on a monthly basis. Those living at the home can be assured that staff have received sufficient training, the home has improved the recording of induction training and all staff working at the home have undertaken protection of vulnerable adults training. Those living at the home can be assured that complaints are dealt with effectively as the home maintains a record of complaints with the provision to record any outcomes of investigations. Individuals living at the home can feel safe when travelling in staff cars as copies of staff insurance cover are in place. Those living at the home can feel safe in the knowledge that the home have completed a risk assessment in respect of staff who work alone at the home, however they would be better assured if the Trust developed a policy to cover this specific area. What they could do better: In order to demonstrate that the needs of those living at the home have been fully evaluated it is required that existing care plans in place are expanded in order to fully demonstrate the level of support offered to individuals. It is further recommended that individual’s mental health safety nets and personal profiles are dated in order to reflect when these are reviewed. In order to demonstrate that staff are working in line with current good practice systems it is recommended that the homes policies and procedures refer to the current organisation and also if the homes daily dairies work system is updated. In order that those living at the home are safe and living life without limitation is has been required that individuals risk assessments are reviewed and updated, it is also recommended that consideration is given to re structuring the ‘safe systems of work folder’ in order that only current, required information is contained within this. In order that current and prospective service users are provided with up to date accurate information it is required that the home updates its statement of purpose n order that it reflects the management situation at the home. DS0000003358.V328219.R01.S.doc Version 5.2 Page 7 In order that individuals can maintain confidence in staff ability it is recommended that consideration be given to medication competency being reviewed for staff. 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. DS0000003358.V328219.R01.S.doc Version 5.2 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 DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager takes a lot of care when admitting residents to Charnhill in order to ensure that the home are able to meet the assessed needs of the individual. Clear information is provided about the services and facilities available at Charnhill, although some minor improvements are required to the homes statement of purpose. EVIDENCE: Charnhill Crescent is a care home registered with the Commission to provide personal care and accommodation for up to 4 persons aged 19 years and over with Mental Health problems. All accommodated at the home are female and there are currently no vacancies at the home. Charnhill Crescent is owned and operated by the Aspects and Milestones Trust. The home is one of a variety of care services operated by the Trust focussing on services for adults who require support to live in the community. DS0000003358.V328219.R01.S.doc Version 5.2 Page 10 There was a Statement of Purpose and service user guide available to residents. The Statement of Purpose provides prospective service users, their relatives and professionals with information about the home. The Statement of Purpose was found to be fully comprehensive and contained all of the relevant information required as stated in Schedule 1, Regulation 4(1)(c). . It was found that this document needs minor amendment in order to include the name of the registered provider and manager and to also include details of relevant experience and qualifications. The manager agreed to send a copy to the Commission for Social Care Inspection in order that up to date information is available for reference. Since the last inspection there has been a new admission into the home. This person had moved into the home recently and was currently a few weeks into a month’s trial period. The manager fully demonstrated a clear understanding of the admission process for individuals to the home. Ms Bewley told the inspector about the admission process for the most recently admitted resident to the home. The inspector saw in records that this person was introduced into the home at a level and pace appropriate to them, they visited, stayed for a meal, an overnight stay and then a months assessment period. This month allows time for the individual and the home to determine if the home is suitable to meet the individuals needs, wishes and aspirations. The views of those already living at the home were also taken into consideration. The lady who has moved into the home said ‘I am very happy here, I want to stay, I have made friends’. The terms and conditions, ‘License agreement’ were viewed for all of those living at the home. It was found that these documents contained all of the required information in order that the rights and responsibilities of individual’s were outlined. All of these documents had recently been reviewed and updated with evidence to show that they had been explained to individuals. The home had included information within these contracts, information about individuals fee and what this includes and does not include. There was evidence to show that the home had discussed these contracts with residents and they had signed their contract, as had the manager of the home. Staff spoken with told the inspector that all of those living at the home are treated as individuals, all with different views and values, they were able to give examples of how specific needs are met. The inspector saw that staff have undertaken appropriate training that will equip them with additional skills and knowledge to meet the needs of older people. There are residents living at the home with specialist mental health and some physical healthcare needs; these are being met by staff at the home and other professionals. The support from these services are clearly recorded, their recommended actions are shared with the staff team in order that continuity of care is maintained. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals have access to healthcare support services and are well supported in aspects of their life, however care plans require additional information in order that they fully reflect how individuals are to be supported. Risk assessments are also in need of review and to be updated where needed. EVIDENCE: All individuals said they like living at the home, and that they feel well cared for, that staff listen and treat them well and knew that they have a care plan in place. All knew who to speak with if they had any concern. Care plans clearly documented the personal and health care needs of the residents. It was clear that care plans are updated and kept under review, however in order to fully reflect the assessment mental health needs of individuals and the specialised support given it is required that care plans are expanded and cover all aspects of emotional and mental health support. Since the last inspection the home have consulted with those who live at the home and have developed ‘mental health safety nets’. These contain DS0000003358.V328219.R01.S.doc Version 5.2 Page 12 information about individual’s diagnosis, associated risk factors, individual’s goals and trigger factors of ill health. These contain important information and are written in a person centred way. It is recommended that these and individuals personal profiles are dated n order to show that they are current and are kept under review. Systems for monitoring an individual’s wellbeing were in place and concerns about health were quickly addressed. All of those living at the home are registered with a general practitioner. There was a record of visits to the GP and these were up to date and sufficiently detailed. The inspector also saw evidence to confirm that individuals are well supported with their primary healthcare needs such as optician, dental care and chiropody. All of those that wanted to have had a flu vaccination. Clear information was in place in order to demonstrate that specialist physical and mental health services are accessed for individuals once an assessed need has been identified. One of the residents said; ‘Since I have been supported by the home I have been well (in my mental health) and I thank the staff for that!’ All individuals spoken with said that they are well supported by both staff and external agencies to the home when needed. Medication is well managed with clear records in place and lockable facilities are provided. There are individuals who are supported to self medicate. The resident said that they like to deal with their own medication to maintain their independence. Information was held securely. The home has a policy on confidentiality. Staff were observed ensuring confidentiality when discussing individuals in the communal areas, the office door was also closed when information about individuals were being disclosed. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can keep close contact with relatives,friends and the community. Those living at Charnhill are offered a varied and nutritious diet, and are able to take part in a range of social, activities and are supported to continue with voluntary work. EVIDENCE: During the day the inspector observed how staff responded to residents. She saw that residents were spoken to at regular intervals and no one was ignored or excluded. Residents were offered choices and were enabled to make decisions about their day. The daily records seen confirmed that the home was supporting individuals in respect of their personal goals. This was further confirmed in discussion with staff and two of the individuals living at the home. Staff support residents to participate in the local community in accordance with their assessed needs and individual choices and preferences. Staff ensure that information is given to residents about local activities and staff support individuals both in and out of the home to participate in activities of their choosing such as visiting places of local interest, drama group, luncheon club, holidays and shopping. On the day of the inspection one of the residents DS0000003358.V328219.R01.S.doc Version 5.2 Page 14 told the inspector about a short break they had at the end of the year, another resident told the inspector about the voluntary work they are involved with and how much they enjoy this part of their life. Also on the day of the inspection all of the residents and staff attended a leaving party for a former staff member of the home. All of those living at the home said they maintain regular contact with their family and that family members are made welcome at Charnhill. Four comment cards were received by the Commission from those who live at the home. All responded that they receive the care and support they needed, that staff listen and act on what they say and that staff are available when you need them. All knew who to speak to if they were not happy. Two also wrote that they are happy and like living at Charnhill Crescent. There is a well-furnished comfortable dining room for individuals to have their meals in. The Home operates a rotating menu. Prior to the inspection the menu choices were looked at to see if individuals are being offered a wellbalanced and varied diet. All the choices seen were well balanced, traditional and varied. Those spoken with said they enjoyed being involved with the preparation of meals and shopping. Individuals said they enjoyed the choices and meals offered at the home. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their views are listened to and acted on. Individuals feel that they are safe in their home. EVIDENCE: The home has robust polices and procedures in place to ensure the protection of vulnerable adults. Completed surveys for those living at the home, all stated that they felt safe and secure living at 33 Charnhill Crescent. Communication between individuals living at the home and staff was open and inclusive during the site visit. Resident surveys and in conversation with residents confirmed that staff listen and act upon what they are saying. All individuals were spoken with during this visit no complaints or concerns were raised. All spoken with said that they would speak with the manager or a member of staff if they had any problems. No complaints have been received by either the home or the Commission for Social Care Inspection. No areas of concern were recorded on care documentation. DS0000003358.V328219.R01.S.doc Version 5.2 Page 16 Minor accidents and incidents were recorded and more serious accidents and incidents affecting the well-being of residents had been reported to the Commission for Social Care Inspection. A sample of records of monies held for safekeeping on behalf of individuals was reviewed. Records had been well maintained and all transactions were clear with receipts being obtained. Inventories were in place for individuals and it was seen that these are kept under review and new items are added. It was recommended at the last inspection that these documents are dated. All had been and this good practice is demonstrated. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals live in a Home that is safe and the quality of furnishings are of a high standard and suitable for their needs. EVIDENCE: Charnhill is a small residential care home, and is furnished to a high standard. The Home is situated in Mangotsfield and is close to private houses and a short distance from the local shopping areas of Staple Hill and Kingswood. The house is nearby to bus stops. This helps ensure residents can be a part of the community. The home was found to be well furnished with soft furnishings such as pictures, plants and photographs making for a homely environment. There have been some refurbishment at the home since the last inspection this has included the redecoration of the entrance hall. Residents spoken with were very pleased about the improvements that have been made. Residents DS0000003358.V328219.R01.S.doc Version 5.2 Page 18 confirmed that they are involved in choosing new flooring for the entrance hall area. A recommendation was made at the last inspection that the office window be checked in order to ensure that it was not letting in water, the manager confirmed that the window was not leaking and this was not a problem. All areas seen during the site visit were clean, comfortable and homely. It was evident that residents had introduced their personalities to the home. Residents were observed moving freely around their home. All of those living at the home have a single room. Individuals have a key to their room for their privacy and security. Two of the residents showed the inspector their private bedrooms, these were found to be well furnished and had been personalised in order to reflect individuals tastes, interests and hobbies. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are cared for by sufficient numbers of competent staff that have been recruited following robust processes. Staff are provided with training to fulfil their roles and responsibilities. EVIDENCE: There is a well-established staff team at the home. The use of agency staff is not required at the home, there are no staff under the age of 21 left in charge at the home and staff providing personal care to residents are over the age of 18. At the time of the inspection there were sufficient numbers of staff on duty to meet the needs of those who live at Charnhill. The manager was able to demonstrate that she and the small staff team have developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations. Three staff were spoken with during the site visit had a good insight into the care needs of the residents. Two staff members spoken with had worked in the home for a long period of time, one since the home opened many years ago. Both staff were committed to providing residents with a homely and full lifestyle based on choice and echoed the underpinning aims of the Trust. DS0000003358.V328219.R01.S.doc Version 5.2 Page 20 At this inspection the staff records for four staff members were fully reviewed and altogether three staff members and the manager were spoken with as part of the inspection process. The inspector judges that the manager operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of residents. Written references, protection of vulnerable adults checks and criminal record bureau checks had been undertaken for staff prior to their commencement at work. Staff complete a comprehensive induction and receive ongoing training in order to fulfil their duties. A staff member spoke with great enthusiasm of training they have undertaken. This had included recent training about depression in older people. The staff member said the trainer was motivational and knowledgeable and was able to give specific guidance on how to support behaviours shown by individuals at Charnhill, this had been put into practice and has a positive effect for individuals that live at the home. Other training undertaken by staff, as confirmed by certificates seen, discussion with the manager and information recorded on training records has included: fire safety, healthy eating, diabetes, person centred planning and preventing challenging behaviour, positive response theory. Three requirements were made at the last inspection in respect of staff training, these were that induction training must be recorded, that all staff must receive a minimum of three days paid training per year and that a new staff member must receive protection of vulnerable adults training. A review of records, discussion with the manager and staff confirmed that all of these requirements had been met. A recommendation made at the last inspection was that staff training records should be updated, this had not been fully completed, the recommendation remains and will be reviewed at the next inspection. DS0000003358.V328219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear sense of leadership and direction and is committed in providing a good quality of life for those living at Firgrove. The health, safety and wellbeing of those living at the home are well managed. EVIDENCE: Jo Bewley recently underwent the ‘fit person’s’ process and was deemed competent by the Commission to undertake the role of registered manager. Ms Bewley has over fifteen years experience working in the care sector, with the most recent three years gaining management experience in different settings. Ms Bewley has the following qualifications relevant to the position of registered manager: DS0000003358.V328219.R01.S.doc Version 5.2 Page 22 • • Diploma in Professional Studies Certificate in Counselling During a fit person interview conducted by Helen Taylor on 12/9/06 Ms Bewley demonstrated a clear understanding of her responsibilities to ensure the home operates within the National Minimum Standards of the Care Homes Regulations 2000. Furthermore during both her interview and during the inspection Ms Bewley discussed the promotion of diversity and equal opportunity the Ms Bewley confirmed she would follow policy and procedure and try to keep the issues ‘alive’ during team briefings. The home undertakes the appropriate fire safety checks on both a weekly and monthly basis and staff have received sufficient fire safety instruction. The home had in place a comprehensive fire risk assessment. The Trust has in place clear policies and procedures in areas of staff employment, service user’s finances and health and safety, all of which have been recently reviewed and updated. This guidance provides clear information to staff to inform and guide their practice. It is noted that due to the levels of independence of those who live at the home there are occasions where staff work alone in the house. The home complied with a requirement made at the last inspection and have developed a clear risk assessments in place that underpin this practice. It was also required at the last inspection that the Trust develop a ‘lone working’ policy in order to fully outline staff role and responsibility. This requirement remains and will be reviewed at the next inspection. Regular residents and staff meeting are held at the home and provide an opportunity for open discussion, to raise concerns, ideas and suggestions and to plan for the future. There are sound quality audit measuring processes n the home including an internal monitoring system whereby the manager of another home checks systems of work, reviews records and spends time talking with residents and staff. Reports of the visits undertaken by a representative of the organisation are forwarded to the CSCI on a regular basis, these reports provide valuable information and are a good way for the organisation to monitor quality of the service. DS0000003358.V328219.R01.S.doc Version 5.2 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 2 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 DS0000003358.V328219.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 15(1) Requirement Statement of Purpose to include information about the registered provided and the registered manager. Individuals risk assessments must be reviewed. Care plans must be expanded in order to fully reflect the support need of individuals. The organisation to develop a lone working policy. Timescale for action 02/03/07 2. 3. OP38 OP7 13(4) b 15 02/03/07 02/03/07 4. OP36 13(4) 02/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP27 Good Practice Recommendations Mental health safety nets and personal profiles should be dated. Consideration should be given for staff to refresh their medication competency training. Staff training records to be updated. DS0000003358.V328219.R01.S.doc Version 5.2 Page 25 4. 5. 6. OP38 OP36 OP7 Safe systems of work folder to be reviewed. Polices and procedures folder to be updated. The homes daily dairy folder to be reviewed and updated. DS0000003358.V328219.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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