Inspection on 14/07/06 for 35 & 37 Britannia Road

This inspection was carried out on 14th July 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 & 37 Britannia Road 01/06/07

35 & 37 Britannia Road 08/12/05

35 & 37 Britannia Road 16/06/05

35 & 37 Britannia Road 16/12/04

35 & 37 Britannia Road 05/05/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Britannia Road, 35/37 Kingswood South Glos BS15 8BG Lead Inspector Odette Coveney Key Unannounced Inspection 14th July 2006 09:30 Britannia Road, 35/37 DS0000003398.V303391.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 Britannia Road, 35/37 DS0000003398.V303391.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. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Britannia Road, 35/37 Address Kingswood South Glos BS15 8BG 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 9618661 0117 9608686 brittania.road@sense.org.uk Sense Miss Helen Elizabeth Swash Care Home 5 Category(ies) of Learning disability (5), Physical disability (5), registration, with number Sensory impairment (5) of places Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 19 - 64 years Date of last inspection 8th December 2005 Brief Description of the Service: Britannia road is a five-bedroom home in Kingswood, South Gloucestershire, and was established as a care home for adults in 1999. It has been converted from two semi-detached houses, with a connecting corridor to facilitate staff support. The home is based approximately one mile from Kingswood High Street where there is a good selection of local shops. Other Community facilities available in the Kingswood area include Dial-a-Ride bus services, Leisure Centre, Community Centre and Adult Learning classes. Access to Bristol city centre is easy where there is the full range of facilities you would expect in a large city. The home provides placement for individuals with single, or dual sensory impairment, plus additional learning disability. Adaptations include flashing lights, minicom telephones, and tactile surfaces amongst other things. Accommodation is provided for five adults aged between 19 and 64 years. The home is not able to provide nursing care for individuals and is unable to accept admissions on an unplanned or emergency basis. There are currently four individuals living at the home. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was conducted in order to look at the requirements and recommendations made at the last announced inspection that took place on 8th December 2005 and also to monitor the care and services provided to those who live at the home. Prior to the inspection the inspector received a completed pre-inspection questionnaire, which provided information about the establishment, policies and procedures, information about those receiving a service at the home and information was also provided about staffing and visiting professionals Throughout the inspection process the registered manager, assistant manager and staff spoken with were informative; they engaged and participated fully with the inspection. What the service does well: What has improved since the last inspection? All of the four requirements made at the previous inspection have been met. The home has ensured that those living at the home are supported appropriately with care plans being reviewed and updated on a regular basis. The home has kept the Commission informed of incidents that have affected the wellbeing of those living at the home. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 6 Those living at the home can be assured that the staff have the appropriate skills in order to support them because staff have received core training in areas such as first aid and manual handling. Those living at the home can be assured that medication systems within the home are robust as medication records corresponded with stock medication held. The sleep in facilities available for staff have improved as this room has been redecorated. 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. Britannia Road, 35/37 DS0000003398.V303391.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 Britannia Road, 35/37 DS0000003398.V303391.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. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service and a review of the home’s statement of purpose and the service users guide. EVIDENCE: Britannia Road is a settled household and residents have lived together for a number of years. There have been no new admissions for a many years. Despite the home being registered to accommodate five residents, presently there are four residents living there. With no immediate plans to fill the current vacancy. Comprehensive care management and health need support plans have previously been seen on file. The home has developed comprehensive person centred plans based on wishes and choices from the information provided by the individuals and information gathered during the assessment process, the trial period and as part of the ongoing placement within the home. The daily records maintained within the home provide clear evidence that individual’s current and changing needs are identified and met. Clear information was in place to show the involvement of specialist services and professionals, ensuring a multi-disciplinary approach. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 9 The inspector received a copy of the home’s statement of purpose prior to the inspection that had been reviewed and updated in April 2006. The new document contained information about the new registered manager, the staffing profile for the service, including details of their previous experience, training and qualifications. This document states that the aim of the service is ‘To provide a home that meets the living, educational and specialist support needs of the individual’s who live at the home. To value the diversity of people who have sensory impairments and additional disabilities’. This along with the service users guide provides sufficient information in order to direct prospective residents as to whether the home is able to meet their assessed needs. Britannia Road, 35/37 DS0000003398.V303391.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 quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. The home operates with a good person centred perspective for all residents. Care plans and risk assessments are extremely detailed and are regularly reviewed and updated to reflect the resident’s currently changing needs and choices to ensure that the correct level of support is required. EVIDENCE: Daily records, essential lifestyle documents and care planning information was in place for all of the four individuals. Documentation examined by the inspector was found to be recorded with a high level of information and it was clear that the information had been gathered over a long period of time with the individual involved being central to the whole process. The information in place recorded the individual’s preferred routines and an overview of an individual’s day and well being, these are written in on a daily basis. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 11 These records note what individuals have done during the day and cover areas of communication, activities of daily living, social activities and behavioural monitoring. These records demonstrated that routines for individuals are flexible and tailored to individuals expressed wishes and choices. Care planning information is updated and re-written as and when there is an area of identified need. Information in place also covered areas such as ‘my communication’, ‘my social life’, ‘making choices’ and ‘my personal care’. It was noted that recorded in care records a statement, which said that:‘All staff working at Britannia Road have a duty of care to promote individual’s independence and to empower individual’s to make their own informed choices’. Care records evidence that staff have read and understood each person’s guidelines and that these are followed, this is to ensure best practice and a consistency in staff approach. All care documentation had been recently reviewed within core team meetings, involving the individual, providing an opportunity for this to be undertaken. Therefore, the requirement made at the last inspection that care plans must be reviewed and updated regularly had been met. The inspector saw and heard staff communicating with individuals asking them their opinion and offering choices. Staff were observed using appropriate language, speech and signing. These corresponded with individual’s communication plans. The home has developed comprehensive risk assessments. These have been produced within a risk management framework, without impacting on individual’s expressed choices. These assessments ensure that staff enable individual’s to take responsible risks, ensuring they have they good information on which to base decisions. This is completed within the context of the service users individual plan and of the homes risk assessment and risk management strategies. Action is taken to minimise identified risks and hazards. The home would respond appropriately to unexplained absences by service users according to written procedure. A recommendation was made at the last inspection that an absconding risk assessment should be developed, to include that CSCI should be notified. This document was reviewed and the inspector saw that this information had been included, some discussion also took place with the manager about what incidents should the Commission be notified about. The manager was fully conversant in this area. The home has exceeded the national minimum requirements in this area. Britannia Road, 35/37 DS0000003398.V303391.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): 11, 13, 15, 16, 17. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. Individuals are offered opportunities to personally develop, to participate in activities of their choice and to access community facilities. Respect is part of daily life within the home. EVIDENCE: Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. This was varied and confirmation that activities have taken place was evidenced through written documentation seen and discussion with the manager and a staff member. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 13 Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable service users integration into community life through knowledge and support to enable service users to make use of services, facilities and activities in the local community, such as shops, pubs, and leisure centres. Information seen by the inspector, and confirmed by staff and seen on individual’s records showed that those living at the home are offered a variety of social, leisure and educational activities. Individuals are able to participate or not, this is dependent on the individual’s choice. Information seen in daily records evidenced that individuals regularly take part in the following activities such as arts and social classes, bowling, local community fun days, church, picnics, bingo and playing pool. Helen Swash said that the home regularly review the activities that individuals participate in and monitor these to ensure that individuals are benefiting from their experiences. Individuals have been supported to participate in an annual holiday of their choosing, this year these have included Exmouth, Dublin and centre parcs. Staff support individuals to maintain family links and friendships inside and outside of the home and this is facilitated by staff assisting individuals with correspondence, telephone calls and escorting individuals on visits to family members. Some discussion took place with the manager about opportunities for service users to develop and maintain intimate personal relationships with people of their choice. The manager was fully conversant with respecting the rights and choices of individuals and was able to demonstrate that the home would access specialist guidance if required in order to help service users make appropriate decisions and would be supported, as they required. The manager further said that issues of consent are covered within the organisation’s adult protection training. The manager is undertaking training next week in respect of personal relationships and sexuality. Evidence seen in ‘my activities today’, risk assessments and care planning information and review notes recorded the preferred routines of individuals, activities undertaken, activities of daily living and individuals meal choices. These meals choices showed that individuals are offered nutritious, varied and balanced diet at flexible times. Meals taken by individuals during the past week have included, meat, fish, pasta and vegetarian with fresh fruit and vegetables. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 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. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. Individuals are well supported by staff and external agencies with all aspects of their personal, physical and emotional well-being. Legal requirements in respect of medication are appropriately met. EVIDENCE: The care documentation in place, sampled, provided clear guidance for staff on how they should support individuals with their personal care, it had recorded individual’s preferences and the assistance required with personal hygiene and personal support. Some individuals have complex needs and exhibit some behaviour which challenges, the inspector saw that the home monitors individual’s behaviour and the service provided is tailored to needs of the individual. Staff have received guidance and support to ensure they are equipped with the skills to support service users in an appropriate manner, risk assessments and behaviour strategies are in place to guide staff and to direct practice Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 15 A support worker showed the inspector the medication administration systems in place at the home. The staff member was fully conversant with their role and responsibility in this area and the importance of adhering to policies and procedures that are in place for the safe administration of medication. A review during the inspection revealed no errors. The medication was appropriately stored and was well organised. All medication records were up to date and in order. A requirement was made at the last inspection that medication records must correspond with stock medication held. The inspector saw that the home has improved upon with the recording in this area and therefore the requirement had been met. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 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. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. There are clear guidelines, policies and procedures in place to ensure that individuals are protected from abuse and staff have demonstrated responsibility in this crucial area of adult protection. EVIDENCE: A requirement was made at the last inspection that the CSCI must be notified of any incident that affects the well being of those living at the home. This requirement was made, as there were incidents that had not been reported. This requirement has been met as the home has kept the Commission informed of notifiable incidents. A recommendation was made at the last inspection that individual’s inventories should be dated. A review of this found that this information is kept updated on the computer and is backed up on disk; paper copies seen had all been recently reviewed and updated. The home has robust polices and procedures in place to ensure the protection of vulnerable adults. One of the staff members was asked about their understanding of what constitutes abuse and what their responsibilities in this area would be; the staff member told the inspector of the protection of vulnerable adults training they had undertaken, ensuring the rights of the service user were upheld, not making judgements and the importance of reporting and recording. This staff member demonstrated a sound understanding of this subject. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 17 Some of the service users have complex needs in respect of their emotional health and wellbeing and there have been occasions where this individual’s behaviour has impacted on the safety of others. Management and staff were able to demonstrate a sound understanding of individual’s needs and provided real examples on how best to manage situations. This person’s care plan was a very detailed assessment of need with recorded strategies in order to guide and direct staff practice Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 18 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, 28, 30. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. The quality of furnishings and fittings in the home is good and overall a warm comfortable environment has been created ensuring individuals needs are met, however improvement is required to ensure that areas of the home are well lit. EVIDENCE: Britannia Road is a small residential care home, set within the residential area of Kingswood, the home is two houses linked together it has two storie’s and is detached. There is an enclosed rear garden that service users enjoy, A recommendation was made at the previous inspection that consideration be given to increasing the hours of the handyperson. Following discussion with the manager it is apparent that there will be no increase in the hours of this staff member. This home is the only one within the organisation, Sense, who employs a handyperson to undertake general repairs. The manager confirmed that she has a budget available to her for use in this area and is able to contact contractors herself in order that work can be completed promptly. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 19 A recommendation was made at the last inspection for consideration of redecoration of the sleep in facilities for staff. This has been repainted and this recommendation has been met. Communal areas for individuals use were found to be clean, tidy and odour free. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 20 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, 34, 35, 36. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. Residents are supported by a core staff team who enable residents to be as independent as possible. Recruitment practices safeguard the residents. Regular formal supervision sessions benefit the residents, and staff. EVIDENCE: There are clear aims and values in this home, which are individually focused and centre on the choice, rights and self-determination of the individual. Staff were able to clearly demonstrate this philosophy and it was evident that meaningful relationships had been forged between the staff and those living in the home. Each individual at the home has at least one or two key worker’s to support them with the manager being involved with the monitoring of individual care. It was clear that staff have developed relationships with individuals and have worked together with them and others in order to, identify the needs of the individual and then support their key client in achieving their goals and future aspirations. There was information in individual’s care plan documents and person centred planning information to guide staff to the appropriate level of support that individuals require. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 21 Following an evaluation of training undertaken a requirement was made at the previous inspection that staff must receive training in first aid and manual handling. Information seen within training records, along with confirmation from staff and certificates seen it was clear that this training had been undertaken. The home maintains a clear audit of training that staff have undertaken, and when and for how long it is valid. Training records also show what has been requested. A staff member spoken with said that training is readily available and spoke of their enthusiasm in being put forward to become an assessor for the National Vocational Qualification and how they would be supporting two candidates through the process. The home currently has two staff members who have achieved an NVQ at level three, promoting independence. A review of all staff records was undertaken and full recruitment and selection documents were in place for staff including a completed application form, references, job descriptions and evidence that a criminal record bureau check had been obtained. Files were found to be well ordered. The manager said she is well supported by her line manager and receives monthly recorded supervision, the manager was also able to provide information about the formal supervision structures that are in place in order to guide and support staff practice, another staff member told the inspector of the benefits of supervision and told her about the observations that she undertakes of staff practice. This observation is pre arranged with staff with feedback given to staff to inform and guide their practice. Formal supervision on the whole takes place on a monthly basis. This frequency is above the guidance set by the national minimum standards, demonstrating that supervision is regular and structured. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 22 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, 39, 40, 42. The quality outcome in this area is good; this judgement has been made using available evidence including a visit to this service. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. EVIDENCE: Ms Swash has worked at Britannia Road since 1999. Ms Swash has many years experience within the care profession, supporting young adults with sensory impairments and also a learning disability. Ms Helen Swash has achieved the following professional qualifications: In November 2005 Ms swash obtained an NVQ at Level 3; promoting Independence. Ms Swash is currently undertaking the registered managers award and will register to undertake an NVQ at level four. Other training courses undertaken by Ms Swash include; Supervision and Appraisal, Recruitment and Selection, Disciplinary and Capability, Finance and Budget Management. Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 23 Throughout the inspection Ms Helen Swash was able to demonstrate a clear understanding of her role and responsibilities and how this would influence the service delivered at the home to ensure that services were delivered as outlined within the individual’s care plan, Ms Swash was aware of her role and responsibilities as the registered manager and that she is accountable. Ms Swash was clear about putting those who use the service first, about ensuring individuals were listened to and were given the same opportunities. The atmosphere at the home at the time of the inspection was calm and relaxed with individuals looking clearly at ease and ‘at home’. Accident reports were viewed during the inspection, information crossed referenced with care records and were well written. The home undertakes the appropriate fire safety checks on both a weekly and monthly basis and staff have received sufficient fire safety instruction. Reports of the visits undertaken by a representative of the organisation are forwarded to the CSCI on a regular basis, these reports provide valuable information and are a good way for the organisation to monitor quality at the service. The organisation has in place clear policies and procedures in areas of staff employment, service user’s finances and health and safety, all of which have been recently reviewed and updated. This guidance provides clear information to staff to inform and guide their practice. The home has recently further developed the existing quality assurance and quality monitoring systems based on seeking the views of service users that are in place. These measure success in achieving the aims, objectives and statement of purpose of the home Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 24 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 X 5 X 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 2 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 4 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 X 3 X Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23 (2) p Requirement Two areas in entrance hall to have light fittings replaced. Timescale for action 21/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 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 Britannia Road, 35/37 DS0000003398.V303391.R01.S.doc Version 5.2 Page 27 - 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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