Inspection on 16/11/05 for 34 Sheepwood Road

This inspection was carried out on 16th 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

34 Sheepwood Road 21/02/07

34 Sheepwood Road 18/05/05

34 Sheepwood Road 07/09/04

34 Sheepwood Road 15/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 34 Sheepwood Road Henbury Bristol BS10 7BS Lead Inspector Paula Cordell Unannounced Inspection 16th November 2005 09:30 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 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 34 Sheepwood Road DS0000026608.V261881.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 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. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 34 Sheepwood Road Address Henbury Bristol BS10 7BS 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 9509968 0117 9699000 The Brandon Trust Ms Ruth Martin Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate persons with a Learning Disability and additional Physical Disabilities Residents must be over 35 years old. Date of last inspection 18th May 2005 Brief Description of the Service: 34 Sheepwood Road is operated by Brandon Trust and is registered with the Commission for Social Care Inspection to provide accommodation and personal care to three residents aged 35-64 years of age who have a learning disability. 34 Sheepwood Road is a well established home that has been in operation for fourteen years. It is a residential style bungalow that blends well with the immediate environment and is close to shops and other local amenities. The home provides ground floor accommodation and has one single and one double bedroom. Ms Ruth Martin manages the home. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over a period of 3 hours. The purpose of the visit was to review the progress to the requirements and recommendations from the previous inspection and monitor the quality of the care provided to the individuals living at 34 Sheepwood Road. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at 34 Sheepwood Road and the provider has sent monthly appraisals of the service. The inspector had an opportunity to meet with two members of staff and on of the three residents. The inspector had an opportunity to tour the building and view a number of records including plans of care for two of the residents, staff records and records relating to the safety of the home. The inspector would like to take this opportunity to thank the staff and the residents for their warm welcome and assistance in the inspection process. What the service does well: What has improved since the last inspection? The home has proactively strived for further improvements in the service provision enhancing the quality of the lives of the individuals living in the home. Since the last inspection the home has reviewed the care documentation and introduced a new planning for life folder. This process was still ongoing. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 6 Information was accessible, current and person centred. The home has accessed an external facilitator to assist with the planning of the care. The home has explored ways of improving the communication in the home. This has included developing a memory board for residents on activities and the staff rota, which includes staff photos. Staff are planning future training on communication for individuals who are non-verbal. This is good practice. The home has responded to a recommendation to record food temperatures. 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. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 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 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 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, Residents have access to information about their home and their assessed care needs were being met. EVIDENCE: There was sufficient information in the home to enable residents to make an informed choice on whether they want to live at 34 Sheepwood Road. This included a service user guide, a statement of purpose and a contract between the individual and the service. The service user guide was clear and accessible to individuals with a learning disability and included photographs and symbols. This should be expanded to include the category of registration clearly stating that the home supports individuals with a learning disability. The home was meeting the assessed care needs of the individuals in the home. 34 Sheepwood Road is home to three ladies with a learning disability. The home has been in operation as a care home for the past fifteen years with an established group of residents. The ladies have lived in the home since it first opened. Standard 2 and 4 of the National Minimum Standards is not relevant to the home at this moment in time. However, there are clear policies on the admission process including guidelines for new residents to visit as part of the assessment process. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 9 Assessments were in place for the three ladies based on the activities of daily living, which inform the plan of care. Staff stated that the ladies were happy with their home and described the benefits for the ladies living in a homely environment rather than their previous placements that were long stay institutions. The ladies at Sheepwood Road have their own unique communication methods. This made it difficult for the inspector to determine the views of the residents. However, one of the ladies was observed relaxing in her bedroom and being supported to go out for lunch. She appeared at ease with the staff on duty. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 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): 6,7,8,9,10 Residents had a clear plan of care detailing how they wanted to be supported, it was evident that residents were supported to make decisions and be involved as much as possible within their own limitations. EVIDENCE: Each resident had a plan of care that was based on the principles of person centred planning. Care plans were being reviewed at least every six months with the resident, their family and other professionals where relevant. Since the last inspection the home has commenced the process of changing the care-planning format, which is being universally adopted by the Brandon Trust. In addition the home has completed a PATH for each individual, which was displayed in the bedrooms of the individuals. Staff were keen to share this new planning tool stating that all residents had been involved in the process and were proud of their plans. Staff described how the plans were being actioned and developed as care needs changed. This is good practice. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 11 Monthly summaries were clear detailing any significant information taking from the daily records. This is good practice that will assist the review process. The plans of care were available in symbols and included photographs. This is good practice to ensure that the plans of care were accessible and meaningful to the individual. Risk assessments were in place demonstrating that 34 Sheepwood Road was a safe place to live and work. Risk assessments demonstrated that these did not inhibit but encouraged independence of the resident. Staff spoken with positively described the key worker role (named staff allocated to each resident) and the relationships that had developed. Evidence was found to indicate that the residents are encouraged to make decisions about their lifestyle. For example there was detail in care records about indicators of preferences that were used to facilitate choice. Staff stated that all the ladies make it very clear when they are not happy or do not want to participate in an activity. The inspector gained the impression that the residents were supported to be assertive and where a resident chose not participate these wishes would be adhered to. A member of staff stated that it was difficult to engage the residents in opportunities to participate in the day to day running of the home due to the difficulties in communication and their limited abilities. However, resident views were sought on activities, menu planning and the day was planned with the three individuals as the focus. Staff had a good understanding of their likes and dislikes and this is taken into account on how the day is planned and the running of the home. Staff stated that residents are encouraged to participate in new activities and a record is maintained on the response of the individual. This is good practice. Throughout the inspection the staff were aware of maintaining the confidentiality of the individuals. Conversations about residents were conducted in the office when another resident was present. The home has guidance for staff on confidentiality and this forms part of the induction process. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 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): 11,12,13,14,17 Residents were encouraged to participate in meaningful and varied activities making full use of the community. Residents have a varied and balanced diet. EVIDENCE: Care records were seen for two of the individuals. There were clear plans detailing how the individual was being supported to maintain and develop social, emotional and communication and independent living skills. Information included hobbies and interests. Staff could articulate the content of the care plans and the individual preferences. Residents attend a combination of local colleges and attendance at day centres. One resident attends church on a weekly basis demonstrating the home’s commitment to meet their spiritual care needs. Staff stated that the other residents’ attendance varies but staff support for special festivals for example Christmas. Records demonstrated that the home liaises with the day placements and college courses ensuring that the placement continues to be suitable and all 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 13 parties are happy. Activities were evidently planned to suit the individual and their individual preferences. This is good practice. Residents have access to an annual holiday. Staff stated that the three ladies had a holiday in Weymouth together. However, short breaks were being organised to enable each individual to go away. This was seen in the plan of care for one individual as a goal. Staff stated that although all the ladies went away together there was sufficient staff to enable residents a choice of activities. From care records and discussions with staff it was evident that the residents were being supported to make full use of the community. The home has a house vehicle to enable the ladies to go further afield. It was evident that as part of the key worker role staff were encouraging and supporting individuals to go out at least weekly on a one to one basis. In addition, two of the residents were supported by staff to go swimming on a regular basis. There has been an increase in activities made available to the individuals living at 34 Sheepwood Road since the last inspection. This is good practice and demonstrated a commitment to ensuring residents have meaningful activities. There was clear guidance available in the home on the use of the house vehicle and how this was being funded. There were agreements signed by relatives on behalf of the residents. This demonstrated that the funding was equitable between the three ladies living at 34 Sheepwood Road. The home has explored ways of improving the communication in the home. This has included developing a memory board for residents on activities and the staff rota, which includes staff photos to ensure that information is more accessible. Staff are planning future training on communication for individuals who are non-verbal. This is good practice. Residents have available to them a varied and nutritious menu. Cupboards were well stocked with a combination of convenience and fresh products. Care plans included information about the individual’s dietary needs and preferences. On the day of the inspection a member of staff was making a hearty vegetable soup in response to a request from one of the ladies. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents’ personal and health care was being met. There were robust systems for the administration of medication. However, this could be enhanced if the home sought specific guidelines for each individual on what homely remedies could be used from the prescribing doctor. EVIDENCE: Care plans described the support needs for individuals living in 34 Sheepwood Road in relation to personal care. Discussions with staff and the manager demonstrated that the daily routine of the home is flexible to suit the individuals living in the home. Daily records and care plans confirmed this. Individuals had their own style in clothes – indicating that choice and independence is promoted. The home is liaising with other professionals in the planning of the care ensuring a multidisciplinary approach, complimenting the skills of the staff team. Care records provided evidence that residents had access to a doctor and when required, dentist, optician and other health professionals. Residents have access to preventative health including breast screening, general health checks with the doctor and flu vaccinations. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 15 The home has a Health Action Plan for the each of the individuals living in the home including a hand held record, which residents can take to appointments. This is good practice and demonstrates a commitment to meeting the targets of the government by introducing Health Action Plans for the individuals in accordance with the White Paper ‘Valuing People’. The home has robust procedures and practices on the administration of medication, including a comprehensive induction and training package for staff. This could be enhanced if the home sought guidance from the doctor on the use of homely remedies for each individual. Presently there is a letter from the GP, which includes the names of all the ladies and does not clearly detail what homely remedies can be used. Accident records were seen. The home has had no accident since the last inspection. The manager was aware of the legislation in relation to regulation 37 and the reporting of incidents that affect the well being of the residents. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents have a robust procedure for dealing with complaints however the policy on protection fails to meet the Department of Health Guidance. EVIDENCE: The home has a robust procedure for residents and their representatives to use in the event of a complaint. This was displayed in the dining area of the home. The Commission for Social care Inspection and the home have not had any complaints since the last inspection. There is an outstanding requirement to ensure that the policy on the reporting of abuse is reviewed to ensure compliance with the Department of Health’s Guidance relating to the reporting of abuse called ‘No Secrets’. The policy in the home states that it is the decision of the Director of Services to make the decision whereas the ‘No Secret’s’ guidance states that this is the role of Social Services. One member of the team stated that they had attended training on abuse and could clearly articulate the procedure that would be followed in the event of an allegation of abuse. The home has good financial procedures to ensure the protection of resident’s finances. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 17 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): 24,26,27,28,29, 34 Sheepwood Road is clean and homely and meets the care needs of the residents. There is a high standard of décor and commitment from staff in ensuring that the home is a good place to live. EVIDENCE: 34 Sheepwood Road is a residential style bungalow that blends well with the immediate area. The home benefits from spacious well-maintained rear and front gardens. The home is leased to Brandon Trust from Western Challenge which shares some of the responsibility for the maintenance of the building. The premises were homely, clean and free from odour. The home was decorated to a good standard and furnishings were of a domestic quality. The home has undergone a refurbishment programme including new windows, external doors, a new kitchen and flooring to all communal areas and bedrooms in the last two years. This has enhanced the homely feel and security of the home. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 18 Maintenance records demonstrated that the Trust was responding appropriately to repairs in the home ensuring a safe place for the residents and staff. The home is fully accessible with ramped access to the front door. Bathrooms have been fitted with aids and adaptations to enable residents to be bathed safely. The bathroom and the toilet have been painted with a mural depicting sea life. This is commendable and the inspector would like to acknowledge the hard work that has been put into this providing a comfortable and personalised bathroom. All bedrooms are on the ground floor. There is one single and one double bedroom. There was documentation in care records supporting that the two residents were happy to share. These were personalised and furnished adequately to meet the standards. Communal areas were comfortable and homely. There was a strong commitment from staff in making 34 Sheepwood Road a “home” for the ladies. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 19 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): 31,32,33,34,36 Sufficient and competent staff supports residents. Staff are supported in their role and have clear directions. EVIDENCE: On the day of the inspection two staff were working in the home. Evidence was provided that the home had sufficient staff to meet the care needs of the residents living at 34 Sheepwood Road. There was evidence that additional staff were rostered to provide residents opportunities to go out socially. The home employs a minimum of two staff during the day and one sleep in member of staff on a daily basis. On the day of the inspection there were two staff and one resident at home, an outing had been planned for the individual to go out for lunch with one of the members of staff and the other was planning to complete paperwork. The staff rota was on display in the dining room and to enable the residents to access this information photographs were used to make it more meaningful. This is good practice. Staff on duty stated that there has been a shortage of staff due to personal circumstances of two of the staff including maternity leave. Regular staff and one named bank staff to ensure consistency have covered the shortfall of staffing hours. This is good practice. Staff stated that this has now been resolved with both members of staff returning to work at the end of the month. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 20 The inspector was unable to view staffing information as required under the Care Homes Regulations as this is held at the main office of Brandon Trust. This is an outstanding requirement since April 2002. A member of staff had no recollection of being given a copy of the General Social Care Council’s Conduct. Copies were seen in the office at the last inspection. The member of staff was given details of how to contact GSCC to obtain further copies. This will be discussed at the next inspection. A member of staff stated that all staff are given a copy of a job description and a contract when they commence employment with the Brandon Trust. Each member of staff in addition has a copy of a staff handbook, which includes information about the organisation and policies relating to disciplinary and grievance, and expectations of the worker. Regular staff meetings and one to one supervision provided staff with a forum to discuss and improve their own and staff practices and raise the standards of the care in the home. This was confirmed in discussion with staff and from the minutes of staff meetings. A member of staff stated that the manager meets with them on a one to one basis every four to six weeks and they have recently completed their annual appraisal. Once a member of staff commences in employment they complete the Learning Disability Award Framework and then progress on to an NVQ 2 or 3 in care. This is good practice and demonstrated a commitment to providing residents with a trained and competent workforce. The home is in the process of achieving 50 of the workforce to have an NVQ 2 or 3 by 2005. Two staff have an NVQ in care and a further three staff are in the process of completing out of a team of six. The inspector had an opportunity to meet with the bank member of staff who described good working relationships with the staff and the ladies living in the home. Both staff on duty described a good understanding of the needs of the individuals living in the home. Both staff were enthusiastic about the new care planning system and described a high level of resident involvement. From discussions with staff it was evident that the training was planned around the needs of the residents. Training records were not seen on this occasion and will be the focus of the next inspection. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 Residents benefit from a well managed home. 34 Sheepwood is a safe place to live and work. EVIDENCE: Ms Martin is the registered manager. She has been in post for the past four years. She has successfully completed her NVQ 4 in care and management and is an NVQ assessor. Staff described good management support. Staff displayed a clear understanding of the aims and objectives of the home. Records relating to health and safety were seen. This included risk assessments, fire records, certificates of equipment checks and visual checks completed by staff and records relating to the preparation of food. These were satisfactory. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 34 Sheepwood Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000026608.V261881.R01.S.doc Version 5.0 Page 23 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. Standard YA34 Regulation 17(2) Schedule 4.6 13 (6) Requirement For the records relating to staffing to be held in the home as per schedule 4.6. (Unmet since April 2002) For the organisation to review the policy on the protection of vulnerable adults to ensure compliance with the Department of Healths No Secrets. (Unmet since 18/7/05) Timescale for action 16/01/06 2. YA23 16/01/06 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 To have a protocol clarified with the GP on the use of homely remedies for each individual. 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 24 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 34 Sheepwood Road DS0000026608.V261881.R01.S.doc Version 5.0 Page 25 - 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. 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