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Inspection on 12/09/07 for 35 Valley Road

Also see our care home review for 35 Valley Road for more information

This inspection was carried out on 12th September 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

Residents live in a very homely environment, which has a comfortable and relaxed atmosphere. Health professionals made comments in their surveys such as "treats people as individuals" and "relaxed, positive atmosphere in the home, follow recommendations of visiting professionals". Further, professionals have been impressed with how the service supports individuals to live the life they choose. Relatives` surveys included comments such as "enables them to lead as normal a life as possible" and "they are excellent at meeting the needs of the clients and able to respond to the changing needs in a positive way." And "can`t think of any possible improvement in this caring community." Clear records are maintained and show how residents make decisions and communicate their wishes and needs.

What has improved since the last inspection?

Staff members are developing more pictures aiding residents to communicate their needs. A communication profile is being made for each resident and a community map is being developed for residents to use.

What the care home could do better:

3 requirements have been made as result of this inspection. Residents` contracts must be updated to reflect present fees being charged. Limitations within the home must be included within the Statement of Purpose and Service User Guide ensuring that residents are fully aware of the house rules, and this must be kept under review. A record of the food eaten by residents must be maintained. 1 recommendation has been made for residents to be supported to access local advocates to ensure that they have someone to speak to other than staff with the Trust if need be.

CARE HOME ADULTS 18-65 35 Valley Road Clevedon North Somerset BS21 6AQ Lead Inspector Nicky Grayburn Key Unannounced Inspection 12th September 2007 09:00 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 35 Valley Road Address Clevedon North Somerset BS21 6AQ 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) 01275 879634 0117 9699000 www.brandontrust.org The Brandon Trust Jane Michelle White Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 4 persons aged between 18-64 years with a learning disability (LD) 22nd November 2006 Date of last inspection Brief Description of the Service: Valley Road is a small residential property located on the outskirts of Clevedon. The service has access to local bus routes and is within walking distance of local shops. The home cares for up to 4 adults with learning disabilities. The property is in keeping of the neighbourhood. The service is owned and staffed by the Brandon Trust. The range of fees the home charges is between £941.22 and £945.89. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was 35 Valley Road’s key inspection which was carried out over one day. It was unannounced. The inspector met with some of the residents and staff. There were no requirements to follow up from the previous visit. Prior to the inspection, previous records and reports held at the Commission for Social Care Inspection were read. The Manager also completed the Commission’s ‘Annual Quality Assurance Assessment’ (AQAA) giving basic information regarding the service in relation to the National Minimum Standards. The inspector looked at key documents; talked with and observed residents, a member of staff; and undertook a tour of the property. 4 residents’ surveys; 2 relatives’/carers surveys, and 3 health care professionals’ surveys were received and were analysed prior to the visit, and form part of this report. Residents’ surveys were completed with support from staff. Verbal and written feedback was given at the end of the inspection to the member of staff. A further telephone call was held with the manager to discuss the inspection and to clarify certain issues. What the service does well: Residents live in a very homely environment, which has a comfortable and relaxed atmosphere. Health professionals made comments in their surveys such as “treats people as individuals” and “relaxed, positive atmosphere in the home, follow recommendations of visiting professionals”. Further, professionals have been impressed with how the service supports individuals to live the life they choose. Relatives’ surveys included comments such as “enables them to lead as normal a life as possible” and “they are excellent at meeting the needs of the clients and able to respond to the changing needs in a positive way.” And “can’t think of any possible improvement in this caring community.” Clear records are maintained and show how residents make decisions and communicate their wishes and needs. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. Residents have sufficient information to make an informed decision about whether to move into the home. Residents have written contracts of the terms and conditions of living in their home. Residents’ needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission for Social Care Inspection had an out-of-date copy of the home’s Statement of Purpose and ‘Welcome’ pack. The ‘Welcome’ pack has pictures to enable residents to understand the text and contains a copy of the complaints procedure and the form in Makaton form. This information must include the restrictions within the home as detailed under standard 16. The inspector has requested that the manager send the up-dated ones to reflect current practices and current staffing team. There have been no new residents moving into the home in the past 12 months or since the last inspection. All of the surveys completed by the residents stated that they wanted to move into the home and that they had received enough information prior to moving in to make an informed decision about their move. An added comment on the survey was “I made several 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 9 visits to Valley Road, had tea there, spent time with other people living there, this was over several months. I also went on outings with Valley Road”. The Annual Quality Assurance Assessment (AQAA) stated that all the residents have had an assessment carried out by health and social services. These were viewed and read by the inspector. The assessments are regularly reviewed to ensure that the home can continue to meet the residents’ needs. 1 out of 2 of the relatives survey said that the home ‘always’ meets the needs of the relative in the home, 1 relative said ‘usually’. The AQAA stated that all the residents had a copy of their ‘Places to Live agreement’. The inspector saw these in the residents’ bedrooms. The copies kept in residents’ files were dated 2003. These must be updated to reflect current fees charged. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. Residents have care plans and action plans ensuring that their needs and wishes are met. Residents are able to make decisions in their lives and are consulted upon the their home. Residents are able to take risks within their lives safely. Limitations within the home must be clearly stated in the home’s information. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector viewed 2 residents’ care plans. The plans are written with a person centred approach detailing the residents care needs and history. There is a section called ‘Who is ***’ explaining the residents’ personality and characteristics. An action plan is in place to ensure that the residents’ needs are met. These documents have some pictures to aid the resident to understand the content. The member of staff confirmed that the activities had taken place and daily entries confirmed that activities had taken place. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 11 However, the monthly reports had not been completed since May 2007 and August 2007. Reviews occur and a series of visits from the local funding authority have kept the newer resident’s care plan under regular review. Tutors from the local college also sends and visits the home to inform them on how residents are developing. The daily entries are very detailed giving a full picture of the day, and use appropriate language. Risk assessments were read and enable residents to take risks safely within their life. Some of these were dated with the review date but was not clear as to who had written or reviewed them. Staff must remember to sign these documents. All 4 residents stated on their surveys that they can do what they want during the day, evening and weekends. The AQAA stated that a way the home has improved has been developing picture books for those residents with little or no verbal communications. A plan for improvement, as stated in the AQAA, is to develop communication profiles. The inspector viewed the start of this and is good practice. A member of staff is collecting photos of the local amenities enabling residents to communicate where they would like to go. Residents can attend house meetings and minutes are taken. The inspector read these and were in very good detail and details how the residents communicate their wishes. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. Residents enjoy a lifestyle which suits their needs. Residents have opportunities to access local facilities and can choose how they spend their day. Residents are given a varied diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, 2 residents were on holiday. Residents’ meetings, the home’s diary, residents’ daily entries and staff meetings evidenced that there is a good choice of activities within the home; in the local community, and further a field for the residents, which they partake in regularly. The AQAA and daily entries confirmed that residents attend day centres and colleges. When the residents are at home, they are offered one-to-one time with a member of staff. They are encouraged to carry out ‘life skills’ chores such as 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 13 cleaning and laundry. The member of staff informed the inspector that they also suggest doing an activity, something the resident enjoys doing. Within residents’ care plans, family and friends are detailed. The member of staff also discussed this with the inspector. Some residents do not have any contact with family members and have not developed any other close relationships. It is recommended that those in this situation have contact with an advocate (standard 8). Both relatives’ surveys stated that the home ‘always’ helps residents to keep in touch and always keep them up-to-date with important issues. One relative added that “staff ensure that the clients keep regular contact with their relatives and friends”. The home is developing a community map to help residents to navigate their way round their local community and to aid them in their communication needs. The home has a vehicle and all the residents have bus passes to aid their access to places. Residents’ preferred routines are detailed within their care plans. These are well written and are clear for staff to follow. The AQAA stated that the residents can lock their bedrooms and open their own mail. It was observed how residents could choose whether to spend time in the shared areas with others or alone in their rooms and the garden. A limitation within the house is that the kitchen door is locked at 11pm and reopened at 7am due to safety risks. This was discussed with the member of staff. This restriction must be included in the Service User Guide and The Statement of Purpose and be kept under review regularly. In the kitchen, a resident showed the inspector their folders with pictures of meals and foods which residents like and can choose from. There was a good selection of foods in the kitchen with fresh fruit and vegetables. It was observed how a resident was supported with their lunch choice. The member of staff told the inspector that there is always extra and alternatives if need be. However, this could not be evidenced. A requirement has been made for staff to record residents’ choices and alternatives offered. In the office there is a list for suggestions from staff regarding the winter menu. The menu indicates that residents have their personal choice once a week for the house. Staff must ensure that residents have as much input as possible into the menus. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. Residents are supported to access health professionals to ensure their health and personal care needs are met. Medication procedures are robust and protect the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ care plans detail the residents’ health needs. Local health professionals are accessed and residents are supported to regular attend appointments such as the optician, dentist and chiropodist. It needs to be recorded how some residents do not attend certain health appointments due to personal choice as explained by the member of staff. Other health professionals are accessed as and when necessary, such as Speech and Language Therapist; Continence Nurse; Community Learning Disability Team; and Psychiatrist. It was observed how residents’ appearance reflected their personality and an added comment on a survey was “I choose what I would like to wear, drink, eat. I make clear indications if I do not like things”. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 15 Surveys returned by health professionals gave a lot of praise to the home with comments such as “I have been impressed by how the team at Valley Road have proactively sought help for a resident with a health problem”. Health professionals stated they can ‘always’ see the resident in private and staff treat the residents with respect and dignity. This was evident during observations during the inspection. The medication system was inspected with the member of staff. Training in staff files confirmed that staff undertake full training with Bristol College. There are no controlled drugs kept in the home. Some residents have medication to take ‘as and when necessary’ and there is a policy in place to ensure that staff are aware of the procedure. There is a signatory list in place to identify staff’s signature of administration. Each resident has a profile informing staff of details of their medication. These profiles also correspond to the residents’ care plans. The Medication Administration Records were correct and appropriately signed. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most residents are confident that their views are listened to and acted upon. Residents are protected from abuse. EVIDENCE: The residents’ surveys stated that 3 out of 4 residents know how to make a complaint and who to speak to if they are unhappy about anything. From this, 3 out of 4 residents stated that their complaints are ‘always’ acted on, 1 resident stated ‘usually’. 2 out of the 2 relatives’ surveys stated that they also know how to make a complaint and the home has ‘always’ responded to their concerns. The AQAA said that each resident has a copy of the complaints procedure which is easily understandable. This was confirmed when the inspector looked in the residents’ bedrooms and saw the procedure hanging on notice boards. The inspector also read the complaints book which evidenced that complaints are actioned and recorded. A health professional’s survey stated that they had not received any complaints regarding the home. All the residents stated in their surveys that the staff ‘always’ treat them well. Staffing records showed that staff have undertaken training in the Protection of Vulnerable Adults either on a specific course or through their National Vocational Qualification. However, not all staff had their certificates in their files. The member of staff and the AQAA said that all staff have undertaken this training. The manager confirmed that 2 members of staff are in need of this training and are being booked onto the next available training session. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 17 The manager must ensure that certificates evidence the good practice, and this was discussed with the manager. The accident and incident book was also read and showed that appropriate care and measures are taken when incidents occur. Specialist advice and risk assessments are put in place when necessary, such as aggression and selfharming behaviours. 2 residents’ finances were checked and were found to be correct. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is good. Residents live in very homely and safe environment. Residents’ rooms are personalised and bathrooms meet their needs. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 35 Valley Rd is a 5-bed semi-detached house, which is in keeping with the local neighbourhood. The inspector walked around the property with the member of staff. The whole house was clean on the day of inspection and had a very homely and relaxed atmosphere. There is a large lounge and dining area with pictures of the residents and enough seating for the residents to choose from. It was evident that some residents have specific seats which is respected. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 19 There is a fair-sized garden at the rear of the property which is well maintained by both the staff and the residents. There is seating and a summerhouse, which residents can use. The member of staff and a resident told the inspector that it has recently been made more accessible with a new step. A resident proudly showed the inspector areas of the garden. There is 1 toilet on the ground floor and a bathroom upstairs. The bathroom has grab rails to aid residents’ independence. The member of staff said that the tiling had been done recently which has improved the room. The inspector viewed all residents’ rooms which were very personalised and homely with pictures, photos and personal effects. The AQAA stated that the residents can choose to decorate their rooms when they want and have complete choice in the colour, style and accessories. All residents stated in their surveys that the home is ‘always’ fresh and clean. This was evident on the day of the visit. There is cleaning rota, which covers the whole house, which is on display and the member of staff told the inspector about. Cleaning products and policies are in place and are kept in the laundry room. This room is kept locked. Staff support residents to do their laundry. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 Quality in this outcome area is good. Residents are supported by a well-trained and qualified staff team. Residents benefit from staff being aware and confident in their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 35 Valley Road has a staff team of 5 with a manager. There was one member of staff on duty during the inspection as some residents were on holiday. Normally there are 2 staff on duty, with one staff member who sleeps over in case of any emergencies during the night. The inspector viewed the job descriptions and person specifications, which are available to staff at any time. The staff member appeared confident about their role in the home. The AQAA, previous report and staff’s certificates evidenced that staff have a 6-week probationary period including a comprehensive induction to ensure that they are fully aware of how the home operates. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 21 5 staff training records were viewed to ensure that staff are fully trained to work in the home. Certificates are held in staff’s files confirming attendance of training in areas such as First Aid; Fire Safety; Food Hygiene, and Manual Handling. There is a spreadsheet, which the manager keeps to ensure that updates are duly undertaken. Most of these were up-to-date, and training has been booked for the future to ensure all are up-to-date. The staff member told the inspector that Brandon Trust offer staff more training than just the mandatory areas. Staff have also undertaken training in the new Mental Capacity Act which could impact their service. Both relatives’ surveys stated that staff ‘always’ have the right skills and experience to look after the residents properly. Health professionals surveys further confirmed this. A relative wrote in their survey that “communication in the care home is regarded as very important so that all staff are aware of all issues that arise on a daily basis”. Most of the staff have also achieved their National Vocational Qualification level 2 in care. The AQAA stated this and the inspector viewed staff’s certificates confirming this. The inspector observed the member of staff’s interaction with the residents and saw that they could communicate well and understood the residents’ needs and wishes. The home uses additional staff when necessary. The inspector read the minutes from the last few staff meetings. The staff member confirmed that staff attend these meetings to ensure that issues are communicated effectively. The minutes are then duly signed by the staff team. The AQAA stated that all relevant checks and references are secured prior to staff being employed in the home. However, these records could not be inspected, as the manager is the only key holder to the cabinet. The Commission for Social Care Inspection has an agreement with Brandon Trust for staff’s Criminal Records Bureau Checks to be held at their head office. The inspector who carried out the home’s previous inspection reviewed the home’s staffing records and found them to be in order. The manager must make the records available for the next inspection. The AQAA stated that staff receive supervisions on a minimum of 6-weekly basis. However, this standard could not be fully inspected as the records were not available. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is good. Residents benefit from a very well-run home. Residents are protected by the health and safety measures in place. The home has a good quality assurance system in place to develop the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Despite the manager not being present during the inspection, it was evident that the home is well run. The current manager is on a secondment in the home for another 6 months. It was clear from staff and the AQAA that the home would like a permanent manager in place to retain consistency for the residents. The manager is currently doing their Registered Manager’s Award. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 23 The AQAA was received within the given timescale and provided good information to the Commission for Social Care Inspection prior to inspecting the home. Records within the home are well organised and are up-to-date. The office is extremely organised which enables staff to locate information quickly and efficiently. The AQAA confirmed that policies and procedures are up-to-date. This standard was not fully inspected during this visit. The home has a comprehensive quality assurance system, which reflects Brandon Trust’s organisational quality standards. Action plans and improvements are established from the audits. It would benefit from evidencing residents’ and their supporters views to ensure that their views underpin the development of the home. Monthly visits to the home are carried out by the Trust. It was requested by the inspector during the phone call to the manager that copies of these reports are sent to the Commission for Social Care Inspection. The AQAA gave details of when the last health and safety checks had been carried out. The inspector saw external contractors certificates confirming that residents are protected by regular checks. The inspector also read the fire safety folder which evidenced that staff undertake regular checks to ensure that all the fire fighting equipment works properly. Regular fire drills are carried out and the manager must ensure that all staff have participated in these. This was discussed with the manager. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 3 X 3 3 X 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA5 YA16 Regulation 5(b) 4(a) Requirement Residents’ contracts must be updated to reflect current fees charged. Limitations within the home must be included in the statement of purpose and Service User Guide, and must be reviewed regularly. Staff must ensure to record what residents eat according to Schedule 4. Timescale for action 30/11/07 30/11/07 3. YA17 Schedule 4 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA8 Good Practice Recommendations Manager to contact a local advocacy service for those residents who may require an advocate. 35 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Valley Road DS0000008088.V344976.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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