Inspection on 05/10/06 for 33a Hampstead Road

This inspection was carried out on 5th October 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 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

33a Hampstead Road 22/09/05

33a Hampstead Road 13/04/05

33a Hampstead Road 24/11/04

33a Hampstead Road 28/06/04

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 HOME ADULTS 18-65 33a Hampstead Road Brislington Bristol BS4 3HL Lead Inspector Andrew Pollard Key Unannounced Inspection 5th October 2006 09:30 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 33a Hampstead Road Address Brislington Bristol BS4 3HL 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 9077219 0117 9709301 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Hilary Frances Edwards Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 9 Adult patients suffering from Mental disorder excluding those detained under the Mental Health Act 1983 Staffing Notice dated 28/03/2002 applies Manager must be a RN on parts 3 or 13 of the NMC register Date of last inspection 22nd September 2005 Brief Description of the Service: The home is operated by Milestones a branch of the Aspects and Milestones Trust, a publicly funded charity. The home is registered to provide nursing care for 9 adults with continuing mental health needs but has limited scope for dealing with physical or age related health problems leading to physical disability. The home is located a short walk from local shops and a main bus route to Broadmead. The aim is to create a person centred home, which is relaxed and homely as well as maintaining residents life skills and providing therapeutic support when needed. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used In the production of this report; observation, pre-inspection questionnaire, discussion with residents and staff, relative and residents surveys, tour of the home and sampling policies, records, care plans, meals. The emphasis of the service remains continuing care and where appropriate the long-term aim is to lead people toward a more independent lifestyle in the community. In addition staff strive to enhance the quality of life for the residents. Hampstead Rd is a person centred home is relaxed and homely and seeks to maintain residents life skills providing therapeutic support where needed. The majority of residents have limited interest in the management of the home other than their attendance at the house meetings. All eight of the residents surveyed said “Staff always treat me well” comments included “I am very impressed”, and “I am very happy here”. The staff interactions with residents witnessed by the inspector were positive and people were treated with respect and dignity. The staff team are experienced with the needs of the resident group. The skill mix and level of Registered Nurse input is appropriate for the resident group. Resident contribution to fees is £383. What the service does well: The manager and staff are operating the home in a person cantered way and seek to empower and motivate the residents to engage more fully with life in and out of the home. When needed the staff have the skills and experience to identify and provide therapeutic interventions and manage the clinical care needs of the residents. There are a wide range of activities and opportunities made available to the residents. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The outcome in this quality area is good Prospective residents have the information they require. Admissions are properly managed for the benefit of the residents. The staff have been successful in creating a person centred home, maintaining residents life skills and providing therapeutic support based upon their assessed needs and aspirations. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 9 The statement of purpose and service user guide have been written in accord with the regulations and schedules and provide clear information for residents, minor revisions have been made since the last inspection. There is one vacancy and there has been one new admission since the last inspection. All admissions are managed through the community mental health team and social services who carry out full assessments of peoples needs. The prospective resident and or relatives are consulted where appropriate. The manager or other Registered Nurse (RN) meets and assesses all referrals prior to admission. People are offered at least a half-day visit followed by an overnight stay. The views of the existing residents are taken in to account regarding any admission. A summary of the assessed needs and a letter confirming the home’s ability to meet the needs is sent to all prospective residents. Discussions with the resident most recently admitted and their family indicated that the admission process had been well managed and successful and all parties were happy with the placement. A full multidisciplinary review of the placement was carried out 4 months after admission. Residents have a licence agreement setting out their terms and conditions. All residents can read and most have signed the agreement. All residents are awaiting a full multidisciplinary reassessment of their needs, as there is a proposal to change the registration category of the home to a non-nursing environment in the future. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 The outcome in this quality area is good There was good evidence of needs and risk assessments reviews being carried out and clearly written care plans. Residents are involved with decision-making and consulted about the running of the home within the limits of their willingness or ability to take part. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 11 All residents have a person centred care plan, which they were encouraged to take an active part in developing. Some residents require staff support in this process and some play a very limited part. All of the residents who responded in the survey said, “Staff listen and act on what they say”. A thumbnail biography called “about me” is written, along with “things you need to know about me”, what is essential, important and “what I do and don’t like”. Each element of the care plan is written up separately and in the main signed by the resident. Reviews are recorded on the rear of the plan. Enhanced level care plans and medical information are also part of the case file. There are six monthly multidisciplinary reviews to which residents are invited. All residents have a named Registered Nurse and Care Assistant key worker. The named Nurse and key worker evaluates each care plan element at least every two months. The staff write daily notes at each shift change. Individualised risk assessments have been written and are held in each person’s case file along with skills assessments and competences. The main areas of risk identified are: falling, bathing, smoking, use of alcohol and previous mental health history and medication compliance. Any restrictions on personal freedoms were documented in care plans. The majority of residents show little interest in the management of the home other than their attendance at the residents meetings, which are generally well attended. Eight residents returned surveys only one indicated they wished to speak to an inspector but declined on the day. Six people indicated in the survey “they make decisions about what they do each day”. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17, The outcome in this quality area is good Staff strive to enhance the quality of life for the residents. Residents regularly make use of community facilities and services. From speaking to residents and reviewing records it was evident that the food provided is to peoples liking and offers a generally balanced diet. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 13 The emphasis of the service remains continuing care and some rehabilitation, also to maintain the existing life skills that people have. Where appropriate the long-term aim is to lead people toward a more independent lifestyle in the community. However the future function of the home is not clear as consideration is being given to de-register the nursing component of the home. Most of the residents make use of community services and facilities. However, The long-standing mental health needs of the residents often militate against the likelihood of future employment or further education. Two residents work in a voluntary capacity dog walking for the dogs home and as a grounds-man at Arnos Vale cemetery. Residents attend various venues including Bristol College and the city farm. Two residents regularly attend the social/drop in centre at St Johns each week. Three or four residents attend the local church from time to time. Holidays or short breaks have been arranged this year including a trip to Liverpool and Dublin. An activity organiser, Mr Cains has been employed full time over five days engaging residents with in and out of house occupation and recreation. In the main these activities are arranged on a one to one basis based around the residents choice. Mr Cains chairs the residents meetings the most recently at the end of August for which notes were seen. Current issues being discussed include plans for Bonfire night, day trips and Christmas planning. It is hoped that residents will have free view TV installed soon. A flexible arrangement of working hours is in place to support evening social activities and days are set aside to take people out. Seven people who responded to the survey said, “You can do what you want in the day time, evenings and at weekends.” A number of residents have regular contact with family members or friends, however in some cases residents have lost contact with family or do not wish to have contact. Family and friends are welcome to visit the home at the invitation of the resident. A number of residents go out with or visit relatives. All seven of the relatives that responded to a survey said, “They were made welcome when they visited the home.” There are three meals a day and the times are flexible. There is active involvement of the residents in choice of meals and requests for individual likes are discussed at the weekly meetings or catered for on a dayby-day basis. Some residents are involved in assisting with meal preparation and one person largely self caters. Other residents do prepare snacks with varying levels of support. From consultation with residents it was evident that the food provided is to peoples liking and offers a varied diet. Records of food served are kept for a month. There are no special cultural needs at present although one person does not 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 14 eat roast pork. There is one person who is a diet controlled diabetic. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 15 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 The outcome in this quality area is good The medication policy of the home is being complied with. There are effective arrangements in place to meet residents mental and physical healthcare needs. The home has all the specialist equipment required to meet the resident’s needs. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 16 All residents have a medication profile. Only one resident is assessed as safe to self medicate and have full custody of their drugs, which is closely monitored. Another residents has previously selfmedicated but this was temporarily suspended due to some anxiety, it is hoped to gradually re-introduce this in the near future. Competence assessments and a supporting policy for self-medication were seen. There is a local medication policy as an adjunct to the Trust document. Registered nurses administer all other medication. All Registered Nurses are Registered Mental Nurses apart from one Enrolled Nurse (M). Two residents have depot injections, three people are prescribed PRN medication and one person has a catheter. The home has a file containing drug alerts. The receipt and administration and disposal records were in order. Weekly stock checking takes place. Pethadine is the only the Controlled Drugs in use and is properly stored but the records are not recorded in an appropriate format. All residents remain under the care of a consultant and the Senior House Officer visits at least every four to six weeks. One resident is currently in hospital undergoing test for deteriorating physical health care. All residents are registered with a local GP practice that makes any referrals for any paramedical services required. The GP returned a survey, which gave positive ratings for the performance of the home and the care provided. Dental checks and eye tests are arranged for those who wish for such. Three people are able to be independent in accessing medical services the others require general support. All residents need some degree of prompting or support in managing their personal hygiene. There are two people who have limited mobility and use a bath seat One person uses a pressure-relieving mattress and has a wheelchair for outdoor use. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The outcome in this quality area is good The staff are aware of the Trusts complaints and Protection Of Vulnerable Adults (POVA) policies and are trained in putting them into practice to protect residents from abuse. The residents are aware of the complaints procedure and attend meetings to give their views on the running of the home. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 18 The complaint procedure meets CSCI requirements and is available to residents and families where appropriate. All residents who responded to the survey indicated, “They were aware of whom to complain to if they were unhappy with their care”. Each resident has been given a copy of the complaint procedure and a flow chart is pinned to the notice board to raise people’s awareness of the process. The relatives who responded indicated, “They were aware of the procedure but had never had cause to complain”. There is a complaint log and suggestion book in place no complaints have been made. The residents spoken with had no complaints. The Bristol “No Secrets” guidance was available (The manager is going to acquire an updated copy) as was the whistle blowing and a POVA policy. All of the staff have attended alerter level POVA training and further updates are planned. The manager has attended training and updating in POVA through the Local Authority. Copies of the GSCC code of practice have been issued individually to the care staff. Each resident has a specific case file relating to his or her finances. All residents have a balance sheet for any monies held for safekeeping and receipts supporting expenditure. All money is checked daily and double signed. All residents have a bank account, some of who require varying levels of staff support with managing their finances, a number handle their own personal allowance. One person is able to fully manage his or her own finances. Four residents countersign cheques along with specific nurses. An internal Trust audit has recently been carried out and, no irregularities were identified but some documentary recommendations made. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 19 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): 24,25,27,28,29,30 The outcome in this quality area is good The house is a clean, comfortable and safe environment for the current residents. The bedrooms and communal rooms and facilities are suitable for their purpose and meet the resident’s needs. Residents have any specialist equipment they presently require to promote their independence. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 20 The home is suitable to meet the current needs of the residents who are all ambulant, however one resident is becoming increasingly frail and their placement is under review. The relocation of the office and creation of a ground floor bedroom has not taken place; no definite date has been identified to commence the work. The home was clean and in good general order. Seven residents said “The home was always clean and fresh” and one person said “Usually”. One person commented, “Julie (housekeeper) does a good job”. Residents take some responsibility for maintaining their own rooms. Risk assessments are carried out to determine if residents are unsafe to smoke in their bedroom. The fittings and furnishings are of a domestic nature and are in good order. The heating, lighting and ventilation are satisfactory. Appropriate arrangements are in place for maintenance and servicing of plant and equipment, for which records are kept. Bedrooms are decorated and furnished in accord with resident’s wishes. The new resident was happy with his room and liked the colour. In general bedrooms are personalised but plain but this reflects to some extent the residents lack of motivation and the fact that people do not generally spend much times in their rooms. Rooms are lockable and residents have access to keys if they wish. There are two bathrooms and they are suitable for the residents needs. The bathroom on the ground floor has a toilet, handrails a shower and hydraulic bath seat installed. The first floor bathroom contains a bath and shower. A communal toilet on the top floor services the two upper bedrooms. Communal areas include a dining room, lounge and smoking lounge. A large tropical fish tank has been installed and a cat has been adopted which a number of residents enjoy. The kitchen has been completely refurbished and refitted and is of an appropriate type and size. The Environmental Health Officer who re- inspected in May 06 where standards were found to be good has previously given the food hygiene award. A range of new garden furniture has been purchased. The laundry is adequately equipped although the room is awaiting redecoration. Department of Health guidelines on infection control are available. Proper arrangements are in place to dispose of clinical waste. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 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): 32,33,34,35,36 The outcome in this quality area is good An appropriate and robust recruitment procedure is in place. The staff are experienced and trained to meet the individual and joint needs of the residents. The staff skill mix and staffing levels are conducive to maintaining and enhancing the resident’s quality of life. The manager demonstrated a clear commitment and focus on training. EVIDENCE: 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 22 Staffing levels are in accordance with the existing staffing notice. The manager works supernumerary five days per week. Although there have been some failings in this regard due to staff sickness. There is low usage of bank and agency staff other than regular night cover. The staff team are experienced with the needs of the resident group and are client centred. The six residents who responded to the survey said, “That the staff treat them well”. Resident dependency is quite variable depending upon people’s mental state and two people are in poor general health. The skill mix and level of Registered Nurse input are appropriate for the resident group. All the relatives surveyed said, “They felt there were always sufficient staff on duty”. One new care staff has recently been appointed and two staff were transferred from another home. A housekeeper works three hours five days per week and an activity organiser full time over five days per week. All prospective staff spend time with the residents who are asked for any feed back or their opinions. All proper checks are carried out and references sought. All the required staff records are now held in the home. The manager demonstrated a clear commitment and focus on training to enhance the quality of life and standards of care for residents. There is evidence from records and staff comments about learning and updating for all staff in areas relevant to residents care needs. In house training topics in the past have included, schizophrenia, compulsive disorder, depression and anxiety and Electro Convulsive Therapy. Breakaway training has been arranged for all staff. A number of care staff have National Vocational Qualification (NVQ) level 2 or 3. Four staff are on NVQ level 3 programmes. A rolling programme of updates in Health & Safety (H&S), 1st aid, food hygine and load handling takes place. All staff receive six to eight weekly supervision by a cascade system of which written notes are made. The manager conducts an annual appraisal process using documentation supplied by the Trust to create learning development plans. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 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): 37,39,42 The The life. The The outcome in this quality area is good staff are motivated to bring about improvements in residents quality of staff seek to empower the residents and safeguard them from abuse. home is a safe and well-maintained home. EVIDENCE: The manager and nursing staff are experienced in the care for people with mental health needs. There is a low staff turnover in the home and the consistency of staff presence is important to the wellbeing of the residents and maintaining the strategies of care that prevent incidents and tensions arising in the home. The manager Ms Edwards has compleated an Open University “Managing Health and Social care “ course. Whole team meetings and clinical team meetings are held regularly to review practice and standards of care. Regular house meetings are held to access the views of the residents on the 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 24 quality of life and services in the home. All the residents stated that, “The staff treat them well” one person saying, “ I feel confident” and another saying, “I am very impressed”. All seven relatives who responded said, “That they were satisfied with the overall care provided”. Comments from relatives included,” Thankyou for looking after him so well”, “Making real progress”, “We are very pleased with the care”. Home managers meet together on the first Thursday of the month chaired by Mr Conoley the head of Milestones. Mr Green the community manager visits at least monthly and writes the Regulation 26 report. A new quality audit tool has been introduced using a peer review process. Ms edwards will be linked to Acarmens Rd care home for this purpose. The Trust has a comrehensive range of policies and procedures and arrangements to review them. There are a range of local policies in place. Previously residents have indicated that they did not want to be more involved with decision making in the home which remains the case although there is quite good attendence and engagement by a number of residents at house meetings. There is a comprehensive Health and Safety policy and there is a Mr Benjamin a Trust manager has delegated responsibility for such matters. Safety audits take place regularly. All residents have individual risk assessments which were seen to have been regulary reviewed. Each person also has a writtencompetence statement for individual life skills as appropriate. The fire log book, records and alarm/detector maintenance arrangements were up to date and in order. Staff have attended recent fire safety training. The gas safety and electrical safety inspection certificates were in order and continuing service arrangements remain in place. The hoist has been inspected. A log of hot water temperatures is maintained. 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 3 x 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 26 none 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 27 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 33a Hampstead Road DS0000020228.V312684.R01.S.doc Version 5.2 Page 28 - 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!