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Inspection on 18/05/05 for 34 Sheepwood Road

Also see our care home review for 34 Sheepwood Road for more information

This inspection was carried out on 18th May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

34 Sheepwood Road provides personalised care to three residents with a learning disability in a homely environment. Staff were knowledgeable about the care needs of the individuals. Training in place for staff was based on the care needs of the residents presently accommodated at 34 Sheepwood Road. The home has an established resident and staff group. There was a strong commitment to providing individualised packages of care.

What has improved since the last inspection?

Since the last inspection, the inspector noticed that there has been an increase in activities available to residents. Regular trips are organised at weekends and on days when the individuals do not attend their day placements. Staff stated that it is a fundamental role of the key worker to organise a weekly activity on a one to one basis with individuals living in the home. The home has developed a resource on community facilities that are appropriate to individuals who use wheelchairs. Documentation included how the individual responded to the activity and accessibility of the venue. This is good practice. The home has responded to a recommendation to replace the front and rear door of the home and install a security light to the rear of the property. This has increased the security of the property. Since the last inspection the home has replaced carpeting to the lounge, dining room and lino to the kitchen and the bathroom. This has enhanced the homely feel to the environment. The bathroom was in response to a requirement from the inspection in September 2004. Residents are protected by documentation supporting the use of wheelchair straps involving other professionals in the decision process and this has been kept under review.

What the care home could do better:

In order to demonstrate that residents are safeguarded by a thorough recruitment procedure the legislation is clear that staff records must be kept in the home. This is an outstanding requirement and the Commission for Social Care Inspection and the Brandon Trust are currently in discussions about this requirement. The Trust must ensure that residents are protected by a policy on protection, which clearly describes the role of Social Services in leading the process of investigation in the event of abuse taking place in the home. The home is recommended to maintain a record of cooked food temperatures demonstrating that residents are safeguarded during the preparation of food. From discussions with staff it was evident that they used the food probe but no record was maintained.

CARE HOME ADULTS 18-65 34 Sheepwood Road Henbury Bristol BS10 7BS Lead Inspector Paula Cordell Announced 18 May 2005 09:30 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service 34 Sheepwood Road Address Henbury Bristol BS10 7BS Telephone number Fax number Email 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 for Younger Adults 3 Category(ies) of LD Learning disability registration, with number PD Physical disability of places 3 34 Sheepwood Road Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Residents must be over 35 years old. May accommodate persons with a Learning Disability and additional Physical Disabilities Date of last inspection 7-Sep-2004 Announced Brief Description of the Service: 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 34-64 years of age who have a learning disability. 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection following the visit on the 7th September 2005. The purpose of the visit was to review the requirements and recommendations from the previous visit and monitor the quality of the care provided to the individuals living in 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 inspection was conducted over seven hours. The inspector had an opportunity to meet with the manager, three staff and the three residents. The inspector had an opportunity to tour the building and view a number of records including plans of care for three residents, and records relating to the safety and the general running of the care home. There were no vacancies at 34 Sheepwood Road at the time of the inspection. The atmosphere was relaxed and the inspector was made to feel welcome and she would like to take this opportunity to thank the staff, manager and the residents. There is one outstanding requirement relating to the staffing records being held on the premises. These are presently held at the Brandon Trust’s central office. This is currently under discussion with Brandon Trust and the Commission for Social Care Inspection. What the service does well: 34 Sheepwood Road provides personalised care to three residents with a learning disability in a homely environment. Staff were knowledgeable about the care needs of the individuals. Training in place for staff was based on the care needs of the residents presently accommodated at 34 Sheepwood Road. The home has an established resident and staff group. There was a strong commitment to providing individualised packages of care. 34 Sheepwood Road Version 1.10 Page 6 What has improved since the last inspection? What they could do better: In order to demonstrate that residents are safeguarded by a thorough recruitment procedure the legislation is clear that staff records must be kept in the home. This is an outstanding requirement and the Commission for Social Care Inspection and the Brandon Trust are currently in discussions about this requirement. The Trust must ensure that residents are protected by a policy on protection, which clearly describes the role of Social Services in leading the process of investigation in the event of abuse taking place in the home. The home is recommended to maintain a record of cooked food temperatures demonstrating that residents are safeguarded during the preparation of food. From discussions with staff it was evident that they used the food probe but no record was maintained. 34 Sheepwood Road Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 34 Sheepwood Road Version 1.10 Page 8 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 Standards Statutory Requirements Identified During the Inspection 34 Sheepwood Road Version 1.10 Page 9 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 standard(s) 1,2,3,4,5 Residents have access to information about their home. EVIDENCE: Residents have access to a contract of care, a Service User Guide and a Statement of Purpose, which clearly describes the services available to individuals living at 34 Sheepwood Road. This is in an accessible format and written in plain English and includes photographs and symbols. This met with the legislation. Standard 2 and 4 of the National Minimum Standards is not relevant to the home at this moment in time. The home has been in operation for the past fourteen years and has an established resident group. The three ladies have lived in the home since it first opened. The ladies moved into the home prior to the Community Care Act and so were not placed by Social Workers but by a resettlement team employed by the long stay hospital for people with a learning disability. The initial assessments have long been archived. However, the home completes their own assessment of needs based on activities of daily living to identify long and short-term goals. The home has policies and procedures to guide them if and when a new resident should move to the home. The manager demonstrated a clear 34 Sheepwood Road Version 1.10 Page 10 understanding at previous inspections of the National Minimum Standards on ensuring a smooth transition for new residents to the home. The inspector’s observations at the time of the visit, discussions with the manager, staff and reading records held in the home indicated that the home was able to meet the care needs of the residents living at 34 Sheepwood Road. Staff stated that the ladies were happy with their home and described the benefits for the ladies living in a homely environment rather than a long stay institution. The ladies living in 34 Sheepwood Road have their own unique communication methods. This made it difficult for the inspector to determine the views of residents. However, residents smiled when asked if they liked living at 34 Sheepwood Road. 34 Sheepwood Road Version 1.10 Page 11 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 standard(s) 6,7,8,9,10 Residents care needs were being met. EVIDENCE: Three residents care records were seen through the course of the inspection. The home is in the process of changing the documentation to a corporate format. The manager stated that this would be in place for June 2005. Each resident had a care plan that was based on the principles of person centred planning. The home uses the Essential Lifestyle Planning in the planning of the care for individuals. The home has translated the written information into symbols to aid the individual to fully understand. There was a photographic care plan that depicted what was essential to the individual. This is commendable. The plans of care were clear and provided evidence that the individual was the main focus of the process. Care plans were being reviewed at least every six months with the resident, their family and other professionals where relevant. Relative questionnaires received by the Commission for Social Care confirmed the involvement in any changes to the care given to the individuals living at 34 Sheepwood Road. 34 Sheepwood Road Version 1.10 Page 12 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. Since the last inspection the home has documented the use of wheelchair straps. This included the involvement of other professionals and the individual’s relative where relevant. This was in response to a requirement from the inspection in September 2004 and the home has demonstrated compliance. 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 evidently had worked with the ladies for many years and have 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. However 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 Version 1.10 Page 13 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 standard(s) 11,12,13,14,15,16,17 Residents are encouraged to lead active and individualised lifestyles. EVIDENCE: Care records contained information on how the home was supporting individuals to maintain and develop social, emotional, communication and independent living skills. Information included hobbies and interests. Staff could articulate the contents of the care plan and the individual’s preferences. Residents attend a combination of college courses and attendance at day centres. One resident attends church on a weekly basis. On the day of the inspection a member of staff was liaising with the day centre to enable a resident to change their day to enable attendance at college. This is good practice and demonstrated a commitment to advocacy and to ensure residents have a structured timetable that is tailored to the individual. Residents have access to an annual holiday. 34 Sheepwood Road Version 1.10 Page 14 The manager and staff stated that the home has provided residents with more opportunity to access the community. The manager stated that key workers organise weekly activities for the individuals living at 34 Sheepwood Road to participate in more one to one activities, in addition to group activities and trips to the local shops. This was evidenced in the daily care records and on the individual’s activity record. The home has access to a people carrier to enable the ladies living at 34 Sheepwood Road to access the community. There was clear documentation on how the vehicle was funded and agreements signed by a relative. This is good practice and demonstrated equitability. From discussion with staff and the manager it was evident that the home supports residents to maintain contact with friends and relatives. This was confirmed in care documentation. Two relative questionnaires commended the contact the home maintained with them and how they were made to feel welcome when they visited. Residents were observed moving freely around the home choosing where to spend their time, whether in their bedrooms, or in the lounge. Staff stated that there are no restrictions imposed on the individuals’ living in 34 Sheepwood Road. Residents have available to them a varied and nutritious menu. Cupboards were well stocked with a combination of convenience and fresh produce. Residents were observed requesting drinks using a combination of signs and gestures and staff responded appropriately. 34 Sheepwood Road Version 1.10 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 standard(s) 18,19,20 Residents personal and health care needs were being met. 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 choices 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 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. The home has developed Health Action Plans for 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 34 Sheepwood Road Version 1.10 Page 16 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. The manager stated that the home is planning to build on the training of staff in the safe practice of medication administration and all staff will be undertaking a long distance learning pack on medication in care homes. 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 Version 1.10 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 standard(s) 22, 23 Residents have a robust complaints procedure, 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. The home was able to demonstrate that complaints would be listened to and responded to in an appropriate manner. There is a 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. The manager stated that all staff would be attending training on abuse to protect the residents living in the home. In addition 5 of the 6 staff are in the process of completing a National Vocational Qualification and a member of staff stated that abuse is discussed as part of the assessment process. It was clear from discussions with staff that they had a good understanding both of what constitutes abuse and the procedure to follow if abuse is suspected. The home has good financial procedures to ensure the protection of resident’s finances. The manager stated that residents’ bank accounts are in the process of being transferred to a new bank for ease of payment of fees. The manager 34 Sheepwood Road Version 1.10 Page 18 was in discussion with the finance department as to whether it would be possible to stay with the ladies’ original bank as they have dealt with the individuals’ money since the home opened 14 years ago and bank statements are sent to the home rather than the Brandon Trust. This will be followed up at the next inspection. 34 Sheepwood Road Version 1.10 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 standard(s) 24,25,26,27,28,29,30 34 Sheepwood Road is homely and meets the care needs of the residents. 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 who 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. This has enhanced the homely feel and security of the home. 34 Sheepwood Road Version 1.10 Page 20 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. Communal areas were comfortable and homely. A new three-piece suite had recently been purchased which enhanced the homely feel of the home. There was a strong commitment from staff in making 34 Sheepwood Road a “home” for the ladies. 34 Sheepwood Road Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 Sufficient and competent staff support residents however, the home fails to demonstrate the protection of service users through the lack of available documentation of the recruitment process. EVIDENCE: Evidence at this inspection was 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 three members of staff during the day and two staff in the evening to assist with residents going out. It was evident from conversations with staff that individuals were clear on their roles and the expectations of the service. Job descriptions were in place to guide staff. 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. 34 Sheepwood Road Version 1.10 Page 22 Staff described good support mechanisms in place from the manager. Training was in place including an action plan to address shortfalls and future need in addition there were regular team meetings, supervisions and an appraisal system. This is good practice. The home has had a high level of sickness and two staff vacancies. During this time the staff working in the home covered the shortfall. The manager stated that the home has one vacancy and the Trust is working with the home looking at the sickness. Brandon Trust has a policy for the monitoring of sickness. During this time the home demonstrated a commitment to ensure that the home continued to be staffed according to the statement of purpose and the care needs of the residents. Once a member of staff is employed in the home. The new member of staff completes a comprehensive induction and training within the Learning Disability Award Framework after which they will proceed onto completing an NVQ 2 or 3 in care. This is good practice and demonstrates a commitment to providing residents with competent and skilled staff. The home is in the process of achieving 50 of the workforce to have an NVQ 2 or 3 by 2005. Two staff have completed and a further 3 staff are planning to finish in June 2005 out of a team of six. Staff were seen during the inspection supporting residents in a positive manner. Staff were knowledgeable about their roles as carer and the care needs of the individuals living in the home. During conversations with the staff it was evident that the manager kept them informed of the day-to-day running of the home. Staff spoken with stated that the manager meets with them at least every six to eight weeks individually and as a team every two months. This is good practice demonstrating an open and transparent service was being delivered with positive lines of communication. 34 Sheepwood Road Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42, Resident’s benefit from a well managed service. 34 Sheepwood Road is a safe place to live and work. EVIDENCE: Mrs Ruth Martin manages 34 Sheepwood Road. She has been in post for the last four years. Mrs Martin stated that in the last year she has completed her NVQ assessors’ course, the registered manager’s award and an NVQ 4 in care. For the latter she is awaiting verification and certificates. This demonstrated Mrs Martin’s commitment to meeting the National Minimum Standards in respect of the qualifications to manage a care home. The inspector found the manager to be aware of responsibilities and she displayed a clear understanding of the aims and objectives of the home and 34 Sheepwood Road Version 1.10 Page 24 her role as the manager. The manager was aware of the current legislation and how this impacts on the residents living in 34 Sheepwood Road. The manager’s training records demonstrated that she was attending ongoing training relating to the care of the individuals and her management responsibilities. This has included a course on recruitment, group dynamics and appraisals in the last eighteen months in addition to completing the NVQ 4 and Registered Manager’s Award. Staff spoken with during the inspection stated that the manager was open and approachable. The home has a quality assurance tool, which informs the business plan for the home. The manager stated that the quality assurance tool is changing and is waiting for direction from senior management on how to proceed. In the interim the manager stated the home is planning to use the National Minimum Standards to guide until the new tool is distributed in the summer. This will be followed up at the next inspection. Records relating to health and safety were seen. This included risk assessments, fire records, certificates of equipment checks, visual checks completed by staff and records relating to the preparation of food. These were all satisfactory. There is one recommendation for the home to maintain a record of hot food temperatures. Training relating to health and safety was in place with a rolling programme. The manager was able to demonstrate that where a member of staff was due training that this was planned, booked and recorded in the diary and the duty rota. The certificate of insurance was seen displayed in the hallway demonstrating that personal belongings are insured for loss and damage including personal indemnity. The Brandon Trust employs a service development manager to oversee the day-to-day operations of the home. This person is responsible for completing the monthly provider visits in respect of regulation 26. Copies of the monthly reports are being sent to the Commission for Social Care Inspection. 34 Sheepwood Road Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 2 x Page 26 34 Sheepwood Road Version 1.10 21 x 34 Sheepwood Road Version 1.10 Page 27 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 34 23 Regulation 17 (2) Scheudle 4.6 13 (6) Requirement For the records relating to staffing to be held in the home as per schedule 4.6. For the organisation to review the policy on the protection of vunerableadults to ensure compliance with the Department of Healths No Secrets. Timescale for action 18/7/05 18/7/05 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 42 Good Practice Recommendations For the home to maintain a record of hot food temperatures. 34 Sheepwood Road Version 1.10 Page 28 Commission for Social Care Inspection 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 Version 1.10 Page 29 - 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. 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