Inspection on 16/06/05 for 35 & 37 Britannia Road

This inspection was carried out on 16th June 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.

Other inspections for this house

35 & 37 Britannia Road 01/06/07

35 & 37 Britannia Road 14/07/06

35 & 37 Britannia Road 08/12/05

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 Announced 16 June 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. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Britannia Road, 35/37 Address Kingswood South Glos BS15 8BG 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 9618661 0117 9618661 Sense, Dr Tony Best Mr. David Wayne Smith Care Home for Younger Adults 5 Category(ies) of PD Physical disability registration, with number SI Sensory Impairment of places LD Learning disability for 5 Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 5 persons aged 19 - 64 years Date of last inspection 16/12/04 Unannounced 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 future development plans for Britannia road include further plans to “open up” the hallways and provide an increased sense of being in one home. 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 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the two requirements and three recommendations from the last inspection that was conducted in December 2004. The inspection took place over seven hours. During the process three residents, five staff, the registered manager and the representative of the responsible individual visiting the home were spoken with. The inspector looked around some of the building and a number of records were examined. Following consultation with the manager and the staff team it was agreed that those living at the home would prefer to be referred to as individuals within the inspection report, rather than service user and therefore this has been reflected within this report. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need the care you get?’; a copy of this was left at the home to be put on the home’s notice board. The inspector also shared with the home information that the Commission has produced in a picture format providing information for those living at a care home as to what work the Commission does, also given were comment cards for individuals produced with pictures in order that individuals can comment on the service and levels of care provided at the home. What the service does well: The home provides a high level of service at the home that is delivered in a person centred way for those who have complex needs. Through discussion with management, observations of those living at Brittania Road, the staff and a review of care file information, it was evident that appropriate care and support was provided for those living at the home. Services provided within the home and externally have been undertaken in an individualised and person centred way. Those living at the home have a stimulating and varied life at the home of their own choosing. Personal development and growth are encouraged, various informal activities made available and provision of care is tailored to the specific wishes and choices of individuals, relationships between individuals and staff are well established and effective methods of communication both verbal and non verbal have been developed. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 6 The home’s real strength is the commitment from the manager and staff to ensure that individuals are living a fulfilled life, relationships built on understanding and trust that have been established over a long period of time. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 2, 5 There are effective systems for the assessment of individuals needs and contracts have been tailor-made to suit individuals preferred style of communication. EVIDENCE: There are currently no vacancies at the home and there have not been for some time. Comprehensive care management and health need assessments were seen on file. The home has developed comprehensive care plans from the information provided by the individuals and information gathered during the assessment process and during the trial period There has been a great deal of progress in the area of written contracts for those living at the home, requirements have been made at previous inspections that this must be undertaken to ensure that those living at the home are given information of their rights and of the facilities and services which are available to them. The inspector saw that contracts are in place for each individual, each contract seen was different and had been produced in the format that was most understood by the recipient In place were also the purchasing arrangements made between the placing local authority and the home. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 9 Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10 Clear information is held demonstrating individual’s assessed and changing needs are identified. Social activities and community presence are well managed, being tailored to their specific wishes and abilities these were well managed, creative and provide daily variation and interest for the people living in the home EVIDENCE: Those living at Brittania Road have complex needs with sensory impairments and learning disabilities. Support, skill and understanding is required from the staff team in areas of communication, promoting individuality and varying impairments though association with a learning disability. Staff spoken with during the inspection were able to provide an in depth understanding which has been developed through time, patience and relationship building. A new member of staff was clear that it is those who are living at the home who come first, that staff are there to work with individuals in the manner most appropriate and successful for them. Through observation of responses when dealing with inappropriate behaviour it was evident that staff have a good understanding of individual’s support Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 11 needs, this was evident from the positive relationships, which have been formed between those living at the home and staff. The inspector saw and heard staff communicating with individuals asking them their opinion and offering choices. Staff were observed using sign language, speech and individuals communication plans. The home operates a successful system called a ‘circle of support’; each person living at Brittania Road has a core team of staff members who, along with the individual meet up on a monthly basis. The purpose of these meetings is to ensure that individuals needs in all aspects of their life are being met. The planning, to ensure the effectiveness of these meetings takes place prior to the meeting happening, staff spend time with individuals ascertaining from them when they wish to have their meeting, who they wish to attend and areas they wish to discuss. At the meeting the previous action plans and life for the individual is reviewed and new targets are set, it is also an opportunity for exploring new possibilities. There was clear evidence within care records that clients are supported by staff to make decisions about their lives and have been given appropriate assistance that had been tailored to the individual in order that they can make an informed decision. It was clear that where possible clients had been consulted and their input within assessment processes had been recorded in care records such as individuals care plan, person centred plans, client wishes in the event of their death and individual’s preferred routines and choices. The home has developed comprehensive risk assessments which have been produced within a risk management framework, without impacting on individual’s expressed choices. Daily log records record the individual’s preferred routines have been produced in both written and symbol format. 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. Information is stored securely. There are clear guidelines in relation to confidentiality of information; the manager was very clear about the home’s responsibility in this area. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16. Those living at the home are supported to participate in a varied range of activities and relationships with individual’s choices and rights being paramount. EVIDENCE: Information seen by the inspector, and confirmed by staff and individuals showed that those living at the home are offered a variety of social activities. individuals are able to participate or not, this is dependent on the individual’s choice. Information seen in daily records evidenced that residents regularly take part in the following activities; playing computer games, picnics, visiting places of local interest, shopping, having a head massage, jaccuzi, swimming and visiting family. Other activities that individuals told the inspector they participate with are cooking, gardening and going out for coffee. Two of the individuals have had a holiday this year at Alton Towers, another went to Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 13 London. Staff were supporting the remaining individual with a countdown planner in anticipation of their forthcoming holiday. The inspector saw in care records that individuals are supported by staff at the home to maintain friendships and links with their family. The staff support individuals to maintain both telephone contact, e-mail, text and correspondence. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 Individuals are supported in their preferred manner and individuals physical, emotional, healthcare and medication needs are well met. EVIDENCE: All of care files were reviewed and provided evidence that personal support and intimate care provided with the resident’s preferences recorded as an integral part of the care provision. Guidance in relation to personal hygiene, clothing, hairstyles and choice in relation to personal items in the room were evident. The staff present demonstrated an enthusiastic and sensitive approach to individuals and were committed to working in a person centred manner. Staff were observed interacting and supporting those living at Brittania Road in their preferred routines. Some of those living at Britannia Road 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 clients in an appropriate manner. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 15 There was a record of visits to the doctor and these were up to date and sufficiently detailed. The inspector saw correspondence from health professionals, including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required. The systems for administration of medication are good with clear and comprehensive arrangements in place to ensure that individual’s medication needs are met. The home uses a monitored dosage system in order to administer medication, a recommendation was made at the last inspection that the medication returns book should contain the name of the individual to whom the medication referred, the inspector saw that this had been undertaking and medication no longer required had been well recorded. Medication records contained all of the required information in order to direct staff. Medication profiles were in place which included side affects of medication and indicators of these. A staff member provided full information to the inspector on the medication competency which they had undertaken and the six monthly review that is undertaken by all staff, their competency is reviewed with them by the manager. Stock medication at the home is well recorded on individuals medication sheets, however there is no record of medication which is used on an as and when basis being audited and checked, it is recommended that this is undertaken in order to monitor the frequency of medication use. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 22, 23 The complaints process in the home is good and there was clear evidence that individual’s views are listened to and acted upon. The risk of individual’s suffering from any form of abuse or neglect is appropriately minimised. EVIDENCE: Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 17 The inspector saw that within all of the individual’s files was information on how to make a complaint and how individuals would be supported with this. This information was also seen in staff files. Care plans also recorded that the home’s complaints procedure had been explained to individuals on a regular basis during the ‘circle of support meetings’ and during care planning review meetings. The inspector viewed the complaints logbook for the home and saw that there were no recorded complaints. Due to the complex communication needs of the individuals living at Brittania House a staff member was asked to explain how she would ensure that individuals are supported with any complaints or any concerns they may have. The staff member demonstrated that she has a sound understanding of the communication difficulties that individuals have and that speech may not be some individual’s main method of communicating, The staff member said that changes in individual’s behaviour, body language, facial expressions and tone of voice would be observed and recorded. Individuals would be approached in a sensitive manner in order to determine what the problem may be and that all avenues would be explored in order to ensure that the individual was supported in the manner appropriate to them. The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals, this includes a protection of vulnerable adults policy. The inspector saw that all individuals had in place an inventory of their personal effects and belongings, this is regularly checked to ensure this is current. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28,29, 30. 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, with some arrangements are in place to ensure that areas of the home are well maintained. EVIDENCE: The home was situated in a residential area and keeping with the street. The home was close to the shopping areas of Kingswood and Staple Hill. The home has access to public transport and also has use of a car for individuals supported by staff. The homes premises are suitable for it’s stated purpose; it is accessible and safe and meets the individual and collective needs of the individuals. There have been no changes in the services and facilities provided at the home since the previous inspection. The location and layout of the home is suitable for its intended purpose. The home is made up of two houses interlinking with accommodation set over two floors. There is no lift for access to the first floor and therefore individual’s whose rooms are on this level are required to be fairly ambulant. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 19 The home was found to be clean, bright and free from offensive odours. The garden was accessible to individuals and was complimented by shrubs and planting. There was seating for the individuals to enjoy their garden. There is sufficient emergency lighting throughout the home. These are checked monthly. The inspector was able to view one of the individual’s private room during the inspection, the room was spacious and individual in style and furnishings, the room reflected the personal tastes, hobbies and interests of the individual. The inspector saw in the individuals room a television, music system, and photographs of the individual participating in their hobbies and interests. The individual told the inspector they had chosen the décor of their room and had been involved in the selection of curtains for the communal lounge. The ratio of the bathrooms and toilets to the number of individuals was sufficient. These facilities were found to be located near to individual’s bedrooms and near the dining room and lounge areas. Handrails are in place around the home. There are no areas of limited access. The home has sloped access ramps to the rear garden and level access at the front of the home in order to support those individuals who require support with mobility. Lights switches, doors, stair edging and handrails were all distinguished in colour and were more prominent for those with visual impairment. Flashing lights are in place to alert those with hearing impairment that the front door bell and the fire alarm have been raised. During the inspection the home was found to be generally well maintained however a toilet door handle came off in the inspectors hand and in two toilet areas the toilet roll holders were not fitted, the manager explained that general household maintenance is covered by a handy person once every two weeks, due to the nature of those living at the home the home is prone to a high level of wear and tear, it is recommended that consideration is given to an increase in maintenance hours in order that the fabric and repairs in the home are of a good standard for those living at Brittania Road. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 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 The arrangements for the recruitment, selection, induction and training of staff are good with the staff demonstrating a clear understanding of their role. EVIDENCE: The manager is well supported by his staff team, with all staff demonstrating an awareness of their roles and responsibilities. Observation of staff practice demonstrated that they were approachable, good listeners and communicators and were comfortable with individuals who were at ease with them. Upon discussion with staff they were able to demonstrate that they know and support the main aims of the home as set out within the aims and objectives of the organisation and work with those living at the home in an individualised, person centred way they understood and were aware of their responsibility to work within the home’s ethos and in conjunction with organisational policies and procedures. Records reviewed provided evidence that a robust recruitment procedure was in place at the home. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 21 A new staff member told the inspector about their induction programme and gave clear examples of what this incorporated such as health and safety, tour of the premises, record keeping and individual accountability. This staff member confirmed that as part of their induction programme they would also be undertaking other training in key areas such as Manual Handling, First Aid and Food Hygiene. The inspector saw that these areas had been discussed with the individual and had been recorded as part of their supervision and induction record. A staff training schedule was viewed, this detailed all staff training which has been undertaken. Training undertaken by staff has been appropriate to their role and has supported individual’s personal development, training has included deaf awareness, value base, adult protection and National Vocational Qualification at level three. David Smith told the inspector that the organisation facilitates a monthly practice forum which enables staff to look at areas which affect their work, one of the staff members had attended a forum meeting which discussed the Mental Capacity Bill and told the inspector how informative and useful the event had been in relation to the rights of those living at Brittania Road. The manager provides support and regular supervision all of which were appropriately recorded, the manager monitors staff practice and staff training and development needs. David Smith is a training facilitator for Sense and has been involved with staff teams in order to develop their awareness and understanding in areas such as Person Centred Planning, Adult Protection Issues and Sexuality and Personal Relationships. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 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 The home is well managed ensuring individual’s interests are promoted and protected by a confident, supported staff team, within a safe environment. EVIDENCE: The registered manager provides a clear sense of direction, and had strategies in place to ensure staff develop the skills and expertise to undertake the tasks they are to perform. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 23 There was evidence throughout this inspection that individuals and staff are empowered and valued. Mr Smith came across during the inspection as open and approachable and as a manager who encourages opinion and listens to the viewpoint of others. The inspector was informed that individuals are encouraged to participate where appropriate in making choices and decisions upon day-to-day issues which affect their well being. Staff have become skilled at recognising how choices are made, for example, through individuals facial expressions, body language and methods of differing communication. Records reviewed were kept secure in the office, which could be locked when not in use. The records were generally satisfactorily maintained, up to date, legible and in order. The home has very clear policies and procedures in place that cover all aspects of the service, individual’s rights, and staff role and responsibility. The home undertakes the appropriate fire safety checks on both a weekly and monthly basis, staff receive regular fire safety instruction. A comprehensive fire risk assessment is in place to ensure the safety of individuals living at the home and the staff employed to work there. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 4 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x 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 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Britannia Road, 35/37 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 x D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA 20 YA 24 Good Practice Recommendations Medication to be used as and when required must be audited and this audit recorded Concideration to be given to increasing the hours of the handyperson. Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 Page 26 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 Britannia Road, 35/37 D56 D05 S3398 Britannia Road V223936 160605 Stage 4.doc Version 1.30 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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