Inspection on 19/05/05 for 35 Cranbrook Road

This inspection was carried out on 19th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

35 Cranbrook Road 14/06/07

35 Cranbrook Road 27/07/06

35 Cranbrook Road 02/11/05

35 Cranbrook Road 20/09/04

35 Cranbrook Road 21/04/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 35 Cranbrook Road Redland Bristol BS6 7BP Lead Inspector Sam Fox Announced 19 May 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 35 Cranbrook Road Address Redland Bristol BS6 7BP 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 9442021 0117 9709301 Aspects and Milestones Trust Mr Peter Carter PC Care Home 5 Category(ies) of MD Mental Disorder (5) registration, with number of places 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 5 persons aged 40 years and over. Date of last inspection 20 September 2004 Brief Description of the Service: 35, Cranbrook Road is operated by Aspects and Milestones and is registered to provide personal care and acccomodation for up to five people with mental health needs who are 40 years and over. At present there are five men in residence, four of whom have lived at the home for a number of years. It is a small residential house which blends in well wth the local surrounds. It is built on three floors and would not be suitable for anyone with ongoing mobility difficulties. It is close to local facilities and amenities, including shops and public houses. It is also close to a main bus route. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced annual inspection. The main focus was to check the home was following the admissions procedure properly as a new resident has recently moved in. In addition to this certain key records were inspected, including all those relating to health and safety, care plans, staff supervision and training. Evidence was gained through observation, discussion with the manager and staff, and consultation with the residents. The manager also sent a pre inspection questionnaire that was checked against records at the time of the visit. In addition to this three comment cards were received about the service from a visiting Community Psychiatric nurse, a relative and a resident. Comments made on these will be included in the body of the report. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to develop a more formal quality assurance system, which would involve seeking the views of residents, staff and visitors to the home. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 6 This would enable them to continue to maintain good standards. Few changes take place at the home and whilst this is not a negative thing, a quality assurance system would prompt staff to continue to think about the service they provide and to include residents within this. Action also needs to be taken to ensure that all residents have an up to date contract. This is currently being reviewed by Aspects and Milestones. Residents need to be aware of the terms and conditions of living within the home as there are some restrictions on freedoms, for example in relation to taking medication. The manager has also been asked to develop a risk assessment regarding the behaviour of one resident and to consider developing an anti bullying strategy. This would further protect residents from the threat of abuse. 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. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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) 1, 2, 3, 4 & 5 There is an effective admission procedure in place which means that new residents can be assured that there will be the resources and specialist help to meet with their assessed need. Information available about the home is comprehensive and enables prospective new residents to make more informed choices when making decisions about their future. EVIDENCE: A new resident has recently moved to 35 Cranbrook Road. He explained that there were a number of meetings before he moved there and that he got to visit the home with his social worker on a few occasions before making a decision about whether it was the place for him. This was confirmed by the manager and staff who said that there were a number of meetings with mental health specialists so that the home could re-assure themselves that they could provide the right service. The resident said he felt he had made the right decision and had settled well. He said that he had been in hospital for a number of years and that it had not been easy to move. The home has sensitively and slowly helped him through this transition. There were comprehensive assessments in place written by people qualified to do so and minutes of a review meeting that took place when the resident had lived there a month. This meets with requirements of the legislation. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 9 The majority of residents have lived at Cranbrook Road for a number of years and the manager explained that he had taken their needs into consideration before accepting the new resident. This is good practice and has contributed to the current success of the placement. It is a quiet home which suits people who prefer a calmer lifestyle. The home has a Statement of Purpose and brochure which can be used by prospective new residents to gain more information about the services and facilities available. These were inspected and found to contain all the information required by the legislation. The manager is expected to review each document on an annual basis. It was noted that residents do not have a current contract. The manager said that the he was waiting for updated ones from Aspects and Milestones. He said that when he received these he would go through them with residents. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 & 9 Care plans continue to be well written and they allow staff to provide sensitive and consistent support. Staff carefully consider risks and put in place effective boundaries which enable residents to retain their independence. EVIDENCE: Opportunity was taken to inspect the file of the newest resident. This was found to contain a care plan which highlighted individual needs and ways in which support was to be given by staff. These were clearly written and easy to follow. The manager and staff explained that consistency was an important factor with a number of residents who have complex mental health needs and who require set routines. Care plans provide a means through which they can all make sure they follow the same guidelines. Care plans also included psychological needs of the person and detailed how to respond if a resident was distressed or agitated. Cranbrook Road operates a key working system through which each resident has a named member of staff who plays more of a central role in coordinating the services they receive. Discussion with staff indicated that this system is 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 11 still working well within the home and provides a means through which they can act as advocates. Each key worker writes a weekly summary which reflects developments linked to care plan goals and needs. These were found to be up to date and written to sufficient detail. The manager explained that a number of residents require boundaries to enable them to manage their mental health needs. This has led to there being some restrictions on freedoms, including, for example, on consumption of alcohol and access to the kitchen at night. These, however, are clearly recorded on care plans and reviewed at regular intervals. There were no restrictions on freedoms which appeared to be inappropriate. There were up to date risk assessments available for a number of residents which included accessing community facilities, smoking and the use of money. These were clearly written and easy to follow. In addition to this there is a risk assessment for one resident who is able to stay at home alone for short periods of time when the rest of the household are out (this is a rare event and usually occurs during celebrations, for example at Christmas). There was one identified risk on a formal assessment regarding potentially violent behaviour. The manager was asked to find out more about this and, if necessary, develop an in-house risk assessment. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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) 12,13,15, 16 & 17 Staff have the skills to sensitively support residents to access community facilities appropriately. They create an unpressured atmosphere through which they can pursue activities of interest to them. EVIDENCE: The activities that residents pursue throughout the week vary according to their preferences and how well they feel. Records showed that one resident has a voluntary job and goes out a lot of the time. One resident said that they enjoy art and have attended classes. Some residents access support groups. It was noted that residents are sensitively and slowly supported to pursue activities and this approach reflects the needs of those residents currently accommodated. The home would suit people who prefer a calmer and quieter lifestyle. One resident commented that they did not want activities organised for them. Residents were observed going out when they wished and they said that there were no restrictions about this. The home does, however, ask residents to be back by 10.00pm unless previously agreed by staff. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 13 Personal care plans included instruction regarding some behaviours in the community, related to mental health needs, which may increase the vulnerability of residents. There were strategies in place to minimise the risks and residents are not prevented from going out because of these. This is good practice. Two residents told the inspector that they visit their family regularly and this was confirmed through records. It was clear that they are an important source of support to them. The manager said that some residents have a limited circle of friends and this appears to be for a number of complex reasons, related both to their mental health needs and the fact that some have been in long term hospitals for a number of years. The home places an emphasis on ensuring that there are structured daily routines and it is a condition of living at the home that residents take responsibility for household chores. This was observed and confirmed through discussion. Records and discussion with staff indicated that residents can at times be reluctant to do their chores but this is usually overcome through discussion and prompting. Menus provided evidence that residents prefer “traditional” meals. The manager said that he was trying to extend the choice but that often residents were reluctant to try anything new. Two residents said they enjoyed the food and there was plenty of it. Meal times are early and the manager regularly consults with residents to ensure that this is their preference. It was noted that one fridge in the kitchen is kept locked and this was because excessive amounts of things were going missing. Whilst at present this practice is accepted, the manager must keep existing arrangements under review as this could be considered institutional practice. There is a separate fridge in the dining area to which residents have unlimited access. They were observed making tea and coffee throughout the morning. One resident does his own cooking. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 Specialist advice is sought promptly and residents can be confident that they will receive support to manage both their emotional and physical health needs. Residents can be assured that there are safe systems in place for the administration of medication. EVIDENCE: Care plans provided evidence that personal care is an issue for some residents who may have a tendency to neglect this area of their lives. Support needed by staff was clearly recorded and this usually takes the form of prompting. Some residents require firmer boundaries in this respect. Records provided evidence that residents are supported to access the relevant health professionals including mental health specialists. One CPN who filled out a comment card stated that “the North of Bristol Rehab team have close links and work collaboratively with the home.” He went on to say that the service users were well cared for and that standards were excellent. 35, Cranbrook Road operates a monitored dosage system (MDS) to administer medication that is supplied at regular intervals by a local pharmacist. All records held in relation to this were found to be well maintained and met with the requirements of the legislation. There are good systems in place for the stock control of tablets that are not part of the MDS system. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 15 It is a condition of residence that all residents take their medication and consistent refusal would lead to a termination of their placement. The manager did say, however, that medication is under constant review and gave an example of one resident whose levels of medication are being slowly reduced. This was confirmed through records. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 Residents can feel confident that their concerns and complaints will be listened to. Staff are trained so that they can protect residents from abuse. EVIDENCE: Aspects and Milestones have a complaints procedure and the manager has translated this into a more simplified in- house policy. This includes time scales for actions to be taken and the contact number of the CSCI to whom concerns can also be raised. This meets with requirements of the legislation. The manager maintains a logbook of all complaints. Three were made in the last year and concerned the behaviour of one resident which was frustrating other members of the household. This has been dealt with sensitively and appropriately by the manager and staff team. There was one major incident in the last six months regarding violent behaviour that led to the calling of the police. This was unusual behaviour and the manager explained the circumstances leading up to this incident and displayed a good understanding as to why this may have occurred. There are procedures in place for dealing with violent or aggressive behaviour and staff followed these during the incident. It has also been made clear to all residents that such behaviour could jeopardise their placement. Discussion took place about bullying, particularly relating to one resident who can display bullying behaviour. It is recommended that this be more formally discussed by the staff team to ensure that they are consistent in their actions if they consider bullying is talking place. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 17 Aspects and Milestones have a protection of vulnerable adults policy (pova) and the manager said he felt confident this would be effective if an incident of abuse were to take place. Opportunity was taken to speak with the newest member of staff who confirmed he had received pova training as part of his formal induction. He displayed a good understanding of the issues involved and said he would feel able to approach the manager if he saw anything he considered abusive. The manager was unclear as to whether all staff have had pova training. He must ensure that all staff have received this. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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, 30 Residents’ benefit from living in a comfortable, homely and clean environment that is well maintained. EVIDENCE: Cranbrook Road is a domestic style house, located in a residential area of Bristol. It blends in well with the surrounds. The garden to the front and rear of the property are well maintained. The external paintwork is cracked and eroded. It is recommended that this be part of a planned programme of maintenance. All areas of the home were found to be comfortably furnished and homely in appearance. It is well maintained. The décor in the premises reflects the fact that it is an all male household. There is a lounge, which is the designated smoking area, and a large dining room on the ground floor. Whilst bright and airy, the decor in the dining room is beginning to look slightly jaded and it is recommended that this be part of a planned programme of re decoration. Residents were observed having unlimited access to all communal areas throughout the day. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 19 Opportunity was taken to view three bedrooms. These were found to reflect the tastes and personalities of their occupants. One did not have a wardrobe but the resident said they did not want one. The home has a one toilet on the ground floor and two on the first floor. Bathing facilities are sufficient to meet with the needs of those residents currently accommodated. One resident said he was pleased with his room and that he viewed it as his own personal space which was private. Another resident confirmed that they felt their privacy was respected. There is a separate laundry area and the manager said that the washing machine was suitable to meet the needs of the current resident group. The home was found to be cleaned to a satisfactory standard and some of the carpets have recently been washed. Aspects and Milestones have a policy in relation to the Control of Substances Hazardous to Health (COSHH) and there were data sheets about all chemical cleaning materials. In addition to this all residents have been risk assessed as being safe to use cleaning equipment 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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) 32, 33, 34, & 36 The home has an effective recruitment procedure in place for the protection of vulnerable adults. The formal systems in place for training and supervision means that the staff have the skills and motivation to support residents. EVIDENCE: Staffing rotas indicated that there is one member of staff on duty throughout the waking day and that there is one “middle” shift which is used flexibly according to the days events. This is sufficient to meet with the needs of those residents currently accommodated, all of whom can access community facilities independently. Opportunity was taken to look at the recruitment file of the newest member of staff. This was found to include a completed application form and confirmation of a satisfactory police check. Aspects and Milestones have now agreed to keep some personnel records in care homes (as required by the legislation) and the manager said that he would soon be receiving this information. Discussion took place about the importance of storing this appropriately. Cranbrook Road has a small but well-established staff team, the majority of whom having been working there for a long time. It was apparent that the residents benefit from receiving support from people who are well known to 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 21 them. Some changes of staff in the past have led to unsettlement, particularly from some residents who dislike change. A comment from a relative included that they found the staff very friendly and approachable. The newest member of staff said that he felt supported by the rest of the staff team who had made him feel welcome. He also confirmed that he had received a comprehensive induction both formally from the organisation and by the manager in-house. He confirmed he had received statutory training of first aid, fire, manual handling and food hygiene. This was further evidenced through examination of records. He said that he felt pleased with the induction and it gave him the confidence to carry out his duties. Two members of the staff team have achieved their National Vocational Qualification Level three. Records and discussion with staff confirmed that the home has an established, meaningful formal supervision system. In addition to this there were minutes of regular staff meetings. These evidenced that staff are encouraged to take part in the decision- making processes within the home and that their views are listened to. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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, 39, 40 & 42 The home is well run and residents can be assured that there are effective procedures in place to promote their well-being. They an also be secure in the knowledge that their are effective systems in place to protect their health and safety. EVIDENCE: The fire logbook was well-maintained and provided evidence that tests and checks of the system take place at the appropriate intervals. Residents also take part in regular fire drills and records confirmed that they are aware of the need to vacate the building promptly. Records indicated that the manager checks the premises for health and safety issues on a monthly basis. In addition to this he has developed a number of risk assessments related to certain manual tasks within the home. All electrical appliances were tested on 2\2\05. The gas central heating system was serviced on 4\4\05 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 Page 23 There were certificates to evidence that all staff have received their statutory training of first aid, manual handling, fire and food hygiene. It was also evident through records that they receive re –fresher training at the appropriate intervals. The manager has developed a business plan, this was easy to read and included simple, accomplishable goals. This is good practice. The home has yet to develop a formal quality assurance system although they have used residents’ questionnaires in the past. Discussion took place with the manager about ways in which one of these could be established. This will be a major focus of the next inspection. Aspects and Milestones have wide ranging policies and these were available in the office. The manager has developed a number of in-house policies from these, which more accurately reflect working practice within the home. They were well written and this is one of the managers’ strengths. Discussion took place about ensuring that policies are reviewed periodically. The manager should also sign to evidence he has done this. All records seen at the time of this visit were sensitively written and up to Date. 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 35 Cranbrook Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 3 x 3 x D56_26559_35CranbrookRd_223530_Stage4.doc Version 1.30 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. 2. 3. 4. Standard 5 9 23 39 Regulation 5 Requirement Timescale for action 30\6\05 30\5\05 30\6\05 30\9\05 Ensure each resident has an up to date contract 13 (4) (c ) Develop risk assessment for identified need in NMS 9 13(6) Ensure all staff have had pova training 24 Develop a formal quality assurance system 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. 5. Refer to Standard 17 23 24 26 40 Good Practice Recommendations Monitor and review practice of locking fridge Develop strategy for anti- bullying Repaint external woodwork Decorate dining room Ensure all policies are reviewed annually and dated as being done so 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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 35 Cranbrook Road D56_26559_35CranbrookRd_223530_Stage4.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. 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