Inspection on 08/12/05 for 35 & 37 Britannia Road

This inspection was carried out on 8th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 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 14/07/06

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 Unannounced Inspection 8th December 2005 09:30 Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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 961 8661 brittania.road@serve.org.uk Sense Mr. David Wayne Smith 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.V264351.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 19 - 64 years Date of last inspection 16th June 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. Ongoing 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 DS0000003398.V264351.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided and monitor the progress in relation to the two recommendations from the last inspection that was conducted in June 2005. During this inspection any standards, which were not reviewed at the previous inspection, were examined, these included: Information provided to potential and current individuals living at the home, needs assessment, meeting needs, introductory visits and confidentiality. Since the previous inspection the registered manager has left the home. There is an experienced member of staff who is ‘acting up’ on a temporary basis. The registered managers post has been advertised and interviews for the new manager have been arranged for later this month. Those living at the home were not all present during the inspection as they were all busy partaking in activities of their choosing. During the inspection time was spent with the temporary manager and a staff member, a number of records, correspondence from other professionals and assessments were examined. What the service does well: What has improved since the last inspection? Standards of service provision and quality of life for individuals living at the home have remained. Those living at the home are protected by the auditing of stock medication, which is held on their behalf. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 6 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.V264351.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Minor amendments are required to documentation in order to ensure that prospective clients are given accurate information. Individual’s aspirations and needs are met by the home that is committed to ensuring that individuals lead a fulfilling life. Placement agreements are in place and contain appropriate information. EVIDENCE: The home’s registration certificate was on display, this states that the home is registered to provide a service for five young adults with learning disability, physical disability and/or sensory impairment. There are currently four people who live at the home and there are no immediate plans to fill the vacancy. The organisation Sense has produced an organisational statement of purpose, which was forwarded to inspectors in September 2005 as part of a consultation document. The home also has in place a comprehensive statement of purpose, which was produced by the home, and this outlines the aims, objectives and philosophy of the home, its services and facilities. This document also provides information about the staff team and the registered manager. The temporary manager was reminded that this and individuals placement agreements will require amendment once the new manager has been appointed. All of those living at Britannia Road have done so for some time. Helen Swash, the current temporary registered manager was asked to explain what the Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 9 process for admission is into the home. Ms Swash stated that individuals are only admitted to the home following a full assessment undertaken by a care manager, information is also obtained from other professionals supporting the individuals, with most importantly the individual themselves being at the centre of the process with their wishes and views taken into account. Ms Swash said that staff from Britannia Road would visit the individual at their home and they would in turn be invited to visit Britannia Road. Individual’s can come for a day visit, a weekend or an overnight stay; the admission is tailored to their specific requirements. Ms Swash explained that the views and needs of those already living at the home would also be taken into consideration. Ms Swash was also clear on what needs can be met at the home and those that would not. The arrangements for admission to the home are well recorded in the home’s statement of purpose and within the policy and procedure for new admissions to the home. It was evident that the home had initially liaised with the individual, their family and professionals during the assessment process and that the information received during the admission and assessment period enabled the home to develop care plans, these were in place for all individuals living at Britannia Road. Information had been gathered over a long period of time and the inspector saw that the plans in place had been tailored to the specific needs and expressed wishes of the individual and recorded how these will be met. Placement agreements for those living at the home were in place; these outline the aims of the organisation and state that services provided will be personal to the individual and include information about the fees individuals are expected to pay, the facilities and services provided and conditions of the placement. The agreement incorporates how individuals’ needs will be recorded and reviewed and who will be involved to meet these. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Individuals’ assessed and changing needs and personal goals are reflected in individual’s care plans, however care plans must show that they have been reviewed and any amendments must be reflected. EVIDENCE: The care documentation for three of those living at Britannia Road was examined during this inspection. It was evident that the care planning information had been generated from a care manager’s assessment as well as the home’s initial assessment. These cover all aspects of personal and social support and healthcare needs as well as individual’s needs and wishes. Each person’s records very extremely detailed and all areas were covered in depth and ensuring that the individual was the centre of the process. Care records set out how current and anticipated specialist’s requirements will be met through positive planned referrals to identified services. During the inspection two care managers from South Gloucestershire Community Care Department spent a number of hours with Ms Swash reviewing the needs and the care plan of an individual living at the home. There are sound risk assessment processes in place; these are undertaken in a manner, which does not restrict individual’s lives. The assessments in place are Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 11 called PRAMS; Person Centred Risk Analysis and Management Systems. Assessments in place included risk of choking, crossing the road, selfadministering medication and physical intervention. At a recent review meeting it was discussed that there had been occasions when an individual had attempted to abscond. The home had been prompt to complete a full and detailed risk assessment in this area, it was recommended that it be added to this assessment that the Commission must be notified should this situation occur. Weekly timetables for individual’s were completed providing a clear overview of an individual’s preferred routine, demonstrating choices made, social and activities of daily living, communication and relationships with others. These had each been produced in a format of communication appropriate to the individual and included pictures, symbols and photographs. The inspector saw that the terms ‘encouragement’, ‘offer information’ and ‘support’, ‘guidance’ and ‘encourage choice’ were incorporated within care documentation demonstrating a commitment from the staff team to promote individual choice and respecting the individual’s as adults. One of the individual’s at the home is supported to manage their own finances, this is well recorded with guidelines set for staff to support, monitor and maintain the individual’s independence. The home has developed a unique system entitled ‘circles of support’, these are a team of staff who work closely with individual clients, relationships are well established and have been built on mutual trust and understanding. Ms Swash explained that individuals are given the opportunity to meet up with their core team on a monthly basis, either formally or informally at a venue of their choosing, either to partake in activity of their choice or to discuss areas of concern. Records are stored safety and are able to locked. The home has a clear confidentiality policy that covers aspects of written and verbal information. The significance and importance of confidentiality has been discussed with staff during supervision, it was also noted that this area had been discussed during the induction programme for new staff. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 Social activities and community presence are tailored to the specific wishes and abilities of the individual’s. These were well managed, creative and provide daily variation and interest for the people living in the home EVIDENCE: All of those in the home have learning disabilities, and have limited communication skills, some behaviour which challenges and also some sensorary impairments. The information seen within care records demonstrated that individuals are fully 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 observation of individual’s language, expressions and individual’s behaviour. Where decisisions had been made by others on behalf of individuals this had been done so in consideration of the individual’s best interests and had been well recorded, decisions of this nature are made incorporating multi-diciplinary teams with other professsionals. Some discussion also took place with Ms Swash about the balanacing of individual’s rights and also the home’s duty of care, Ms Swash demonstrated a clear Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 13 understanding in this area and further confirmed that liasion with other professsionals would be made to ensure the best interests and well-being of the individual were being meet. Evidence was in place at the home to show that individuals are enabled by staff to have opportuinities to maintain and develop social, emotional, communication and independent living skills. Individuals are supported with practical life skills and partake in activities of daily living within the home such as preparation of drinks, snacks, shopping and light household tasks. Staff help individuals to continue with their education and to take part in meaninful and fulfilling activities. Weekly records and individuals care plans recorded that individuals attend college, go swimimmg, attend parties, visit the library and go the cinema. During the inspection two of the individual’s went out with staff, another went shopping for personal clothing. Information seen in individuals timetables showed that individuals routines are respected and promote individual choice, an example of this was that one of the individuals had been up partaking in an activity for most of the night and therefore was sleeping in later that morning. In individual’s files information was in place for individuals to be politically active and vote, Ms Swash explained that due to the nature of the needs of individuals living at the home individuals have not expressed a wish to take part in this process. Within individual’s placement agreements there was clear information on the rules in respect of alcohol and smoking,these were reasonable and took into account others living at the home. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Individuals are supported in their preferred manner and individual’s physical, emotional, healthcare and medication needs are generally well met, however improvements in record keeping would evidence staff competency in medication administration. EVIDENCE: The care documentation in place for individuals provided clear guidance for staff on how they should support those living at the home with their personal care. Individuals had recorded their preferences and the assistance required with personal hygiene and personal support. The inspector saw that each person had in place care plan information covering the holistic and varied needs of individuals. The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner; evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody. Other specialist services are contacted when an identified need arises such as physiotherapy and speech and language therapy. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 15 Staff have undertaken medication competency training, which has been provided by the pharmacist who dispenses medication to the home. Information on staff records showed that the manager reviews this competency every six months. A review of the medication administration and recording systems at the home was undertaken. A blister pack system is in place and appears to be effective. A recommendation was made at the previous inspection that the home maintain a record of stock medication held, this has been undertaken, however for one individual stock medication held did not correspond with records maintained at the home. In order to ensure that medication is being administered correcectly it is required that medication records must correspond with stock medication held. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Clear, robust policies and procedures are in place in order to protect individuals from the likelihood of abuse, neglect and self-harm. EVIDENCE: No complaints have been received by either the home or the Commission for Social Care Inspection. No staff members at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. Due to the nature of the learning disabilities and limited communication skills of those living at the home the manager was asked to explain how she would know if an individual living at the home was unhappy; Ms Swash told the inspector that staff have become skilled at recognising changes in individuals behaviour and that changes to this and body language are monitored and recorded. Ms Swash further outlined what actions would be taken to ensure that individuals were listened to and protected. Examples were given of changes in individuals and how these had been interpreted as indicators of dissatisfaction. Ms Swash also stated that the home, and staff members employed act as advocates for individuals and would endeavour to ensure that individual’s rights were protected. Staff have received protection of vulnerable adults training. This is underpinned by clear and robust policies and procedures in place at the home. Through examination of care records in became clear that there had been a number of incidents from one individual in respect of their behaviour. Most of these incidents had been directed towards staff, however there had also been occasions where the individual behaviour could have impacted on those who Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 17 also live at the home. It is required that the CSCI must be notified of any incident that affects the well being of those living at the home. Not all of the individual’s list of personal effects had been dated; it is recommended that individual’s inventories be dated in order that clear audits of individual’s possessions can be maintained. Ms Swash said that the financial process, records and administration within the home are to be audited later this month by an external financial auditor. They will examine bank records; individual’s benefit entitlement, individual’s personal cash, petty cash and house keeping budgets. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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, 27, 30 A clean, hygienic, comfortable and safe environment is provided for those who live at the home, decoration is recommended to improve staff accommodation with additional handyperson’s hours to maintain the fabric and décor of the home. EVIDENCE: Britannia Road is a home in which the environment can at times take a great deal of wear and tear and the staff team are to be commended for endeavouring to maintain standards at the home. A recommendation was made at the last inspection that consideration is given to increasing the part time hours of the handyperson in order that the maintenance and repair of the home is maintained, there has been no change in this area and therefore this recommendation remains and will again be reviewed at the next inspection. A full tour of the environment was not undertaken at this inspection, however it was found that the accommodation for staff who sleep in was in need of decoration, it was clear that this was an area of the house that has been neglected for some time, there was cracking in the wall which is also in need of attention. It is recommended that this room be redecorated. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 19 Emergency lighting is provided at the home, the inspector saw records, which show that this is checked by the home on a regular monthly basis. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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, 33, 35, 36 The relationships between staff and those living at Britannia Road are good, creating a warm, supportive environment in which individual’s quality of life is improved. Those living at the home can be assured that staff employed have been done so following clear and robust recruitment practices and the implementation of organisational policies and procedures. And that staff are well supported and supervised. EVIDENCE: The inspector saw that the home has in place employment documents for staff, these were available and viewed at the inspection, this included references, completed application form, a criminal records bureau check and contracts of their employment stating terms and conditions. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. Procedures are in place to support recruitment practice and the home has a record of forms of identity checked by the home manager prior to a staff member commencing employment in the home. The policies in place provided clear information in order to guide and inform staff in this area. The inspector saw with recruitment documents a checklist to verify what identification had been seen and had been checked by the manager of the home to ensure their validity. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 21 The inspector viewed the files of the three most recently appointed members of staff; these files contained information about the induction that individuals had undertaken at the home; information seen demonstrated that individuals had covered the ethos of Sense, empowerment of individuals, legislation, staff role and responsibilities, legislation and person centred planning. Correspondence also confirmed that a continuation of this is that individuals also undertake corporate induction and core training within the first few months of employment. Staff job descriptions seen are linked into achieving the goals of those individuals who live at the home as set out in individuals care plans. There are no volunteers working at the home. The home has a clear training matrix in place, this provided a clear overview of what staff have undertaken, within the past six months staff have undertaken such as medication competency, British Sign Language, learning difficulties and blind awareness. It was noted that eight staff members are in need of first aid training with seven staff needing to undertake manual handling training, it is required that staff receive training in these key areas and this will be reviewed at the next inspection. Each individual at the home has core staff called the ‘circle of support’, which is made up of key staff to support individuals 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. Those living at Britannia Road benefit from a well-supported and supervised team. The formal supervision provided for staff exceeds the National Minimum Standard, staff see their manager every month and areas discussed covered the translation of the homes philosophy and aims to work with individuals, monitoring of work with individuals, provided professional guidance and the identification of training and development needs. This is in addition to regular day-to-day contact to provide information and guidance. There are procedures in place for dealing with physical aggression towards staff. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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, 42 The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. Records are well maintained with EVIDENCE: Since the last inspection the registered manager David Smith has left. The Commission were formally notified that Helen Swash would be covering the post until a permanent manager has been appointed. Ms Swash confirmed that the manager’s post had been advertised and that interviews have been arranged to take place later this month. Ms Swash was on duty during the inspection, Ms Swash was professional and came across as very knowledgeable and appears to have a clear sense of direction and was able to relate to the aims and purpose of the home. Ms Swash has undertaken periodic training and development in order to update and maintain her knowledge and skills. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 Page 23 Ms Swash was asked what systems are in place at the home in order for staff to raise issues of poor practice, Ms Swash was able to provide clear examples of how staff and other stakeholders are able to voice concerns and to affect the way the service is delivered. Information seen in care records, review notes, discussions with staff and observations demonstrated that feedback is actively sought form those living at the home. One of the individuals living at the home also has the support of an independent advocate. Records required by regulation for the protection of clients and for the effective and efficient running of the business were found to be up to date and accurate; those seen included; care plans, risk assessments, personal profiles, fire safety records, maintenance of equipment, and staff training records. The systems in place at the home ensure so far as is reasonably practicable the health, safety and welfare of those who live, work and visit the home. The inspector viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. A contractor on an annual basis checks portable electrical appliances for safety. A valid insurance certificate was on display in the home. Accident and behavioural incident reports for individuals living at the home were viewed at this inspection; incidents had been well recorded, dated and signed. From the information seen it was evident that situations were handled effectively and individuals are supported in the appropriate manner. A recent health and safety audit had been undertaken at the home incorporating aspects of individual, staff, equipment and the safety of the environment. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 X 2 4 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Britannia Road, 35/37 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 x DS0000003398.V264351.R01.S.doc Version 5.0 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 YA23 Regulation 37 Requirement Timescale for action 08/12/05 2 3 4 YA20 YA35 YA6 13(2) 18(1) c 15 The CSCI must be notified of any incident that affects the well being of those living at the home. Medication records must 08/12/05 correspond with stock medication held. Staff must receive training in 08/04/06 first aid and manual handling. Care plans must be reviewed and 08/01/06 updated regularly. 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. 3. 4. Refer to Standard YA28 YA24 YA9 YA23 Good Practice Recommendations Consideration of redecoration of the sleep in facilities for staff. Consideration to be given to increasing the hours of the handyperson. Absconding risk assessment to include that CSCI should be notified. Individual’s inventories should be dated. Britannia Road, 35/37 DS0000003398.V264351.R01.S.doc Version 5.0 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.V264351.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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