Inspection on 11/05/05 for 384-386 Southmead Road

This inspection was carried out on 11th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

384-386 Southmead Road 28/11/06

384-386 Southmead Road 12/02/06

384-386 Southmead Road 14/09/04

384-386 Southmead Road 01/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 384-386 Southmead Road Westbury On Trym Bristol BS10 5LP Lead Inspector Paula Cordell Announced 11 & 12 May 2005 09:40 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. 384-386 Southmead Road Version 1.10 Page 3 SERVICE INFORMATION Name of service 384-386 Southmead Road Address Westbury On Trym Bristol BS10 5LP 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 9504987 0117 9699000 The Brandon Trust Mr D Lloyd Care Home for Younger Adults 7 Category(ies) of LD(E) Learning dis - over 65 x 1 registration, with number LD Learning disability x 6 of places 384-386 Southmead Road Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Not applicable Date of last inspection 14-Sep-2004 Announced Brief Description of the Service: Southmead Road is registered with the Commission for Social Care Inspection to provide accomodation and personal care to seven persons with a learning disability aged 18 to 65 with one named person over the age of 65 years. The home comprises two adjourning properties. The home is situated in a residential area close to Southmead Hospital and local amenities. There is a large private garden to the rear of the property. All residents are accomodated in single bedrooms. The home has one ground floor room. The home has recently installed a stair lift and adaptations to the bathroom to assist individuals that have mobilty issues and are getting older. Brandon Trust operates the home. Mr Daniel Lloyd is the manager and is presently completing the process with the Commission for Social Care Inspection to become the registered manager. 384-386 Southmead Road Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. The purpose of the visit was to review the progress to the requirements from the inspection in September 2004 and monitor the service provided to the residents living at Southmead Road. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Southmead Road and the provider has sent monthly appraisals of the service. The inspection was conducted over seven and half hours. The inspector had an opportunity to meet with three staff and six of the seven residents. One of the residents had temporarily moved to another home. The inspector had an opportunity to tour the building and view a number of records including plans of care for three residents, and records relating to the safety and the general running of the care home. There were no vacancies at Southmead Road at the time of the inspection. The atmosphere was relaxed and the inspector was made to feel welcome and she would like to take this opportunity to thank the staff, manager and the service users. There are two outstanding requirements. These have been extended due to the change of manager enabling the home to demonstrate compliance. What the service does well: Southmead Road is a homely environment where great attention has been given to the comfort of the residents and their changing needs. In the last few years the home has made changes to the environment to enable individuals to have a single room showing a commitment to providing residents with privacy and meeting the National Minimum Standards. The residents are getting older and along with this associated issues in relation to mobility the environment has been adapted including the installation of a stair lift to meet the needs of the individuals living at Southmead Road. All residents spoken with stated that they were happy and two “wanted to live in Southmead Road until they died”. Further evidencing that the home was meeting the care needs of the individuals. The focus of the care provided was to encourage and support the individuals in leading independent and individualised lives. This was evident in the care 384-386 Southmead Road Version 1.10 Page 6 planning and the consultation process with the residents living in Southmead Road. Staff were aware of the philosophy of the home and described in great detail how this was put into practice. There is a high level of resident involvement in Southmead Road. What has improved since the last inspection? What they could do better: In order to demonstrate that residents are safeguarded by a thorough recruitment procedure the legislation is clear that staff records must be kept in the home. This is an outstanding requirement and the Commission for Social Care Inspection and the Brandon Trust is currently in discussions about this requirement. In order to ensure that residents’ needs are being met staff must attend training relevant to their care. Residents could benefit from more social activities planned both on a weekend and on an evening. Whilst the home has made changes to the environment to assist residents with mobility, the home must assess access to the home by the front and back door 384-386 Southmead Road Version 1.10 Page 7 and ensure that paths are in good working order to prevent falls. In addition residents would benefit from a call bell system being installed to enable them to call on staff in the event of an emergency, as residents are getting older. The Trust must ensure that residents are protected by a policy on protection, which clearly describes the role of Social Services in leading the process of investigation in the event of abuse taking place in the home. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 384-386 Southmead Road Version 1.10 Page 8 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 384-386 Southmead Road Version 1.10 Page 9 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, Residents have adequate information to make a decision to move to the home. EVIDENCE: Residents have available to them a Service User Guide and statement of purpose. These have been updated since the last inspection to include the change in manager and provider. Information was accessible and included plain English, photographs and symbols. Information was available to demonstrate that residents are assessed prior to moving to the home involving relatives and other professionals where appropriate. The home demonstrated that the assessment process was continual and care needs were reviewed to ensure that they could be met at Southmead Road. One resident has temporarily moved to another Brandon home where the staff and the environment have facilities to assist individuals where manual handling is required. The manager stated that Social Services, the resident and the relatives had been consulted and informed of the decision. Records were with the individual and not held in the home, due to this being in response to an emergency it was in the individuals best interests to have the care records with them. However, the legislation is clear that these should be available in the 384-386 Southmead Road Version 1.10 Page 10 home. This will be followed up by a further visit to the home on the individual’s return. The home is seeking support from a team of specialists who specifically support individuals with dementia. The home must apply for a variation to their certificate of registration to include DE where the dementia becomes the primary care need of the resident. There is an outstanding requirement for staff to attend training in dementia. The manager stated that they were in the process of discussing this with their line manager to secure funding and the best way of delivering this to the team and the service development manager is in the process of completing the application to vary the conditions of registration. Residents have contracts, which they have signed, a copy is held on file. This met with the legislation. 384-386 Southmead Road Version 1.10 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Residents are empowered and participate in the planning of their care. EVIDENCE: Three residents care records were seen through the course of the inspection. The home is in the process of changing the documentation to a corporate format. The manager stated that this would be in place for June 2005. Each resident had a care plan that was based on the principles of person centred planning. It was evident that residents had an ownership over their plans of care and are involved in the care planning process. The home uses a number of different care planning formats including PATH, Essential Lifestyle Planning and MAP. Copies were held in bedrooms. This demonstrated that residents were actively encouraged and empowered to make decisions on their care. Care plans were being reviewed at least every six months with the resident, their family and other professionals where relevant. A resident told the inspector that their family would be attending a meeting the day after the inspection. 384-386 Southmead Road Version 1.10 Page 12 Risk assessments were in place demonstrating that Southmead Road was a safe place to live and work. Risk assessments demonstrated that these did not inhibit but encouraged independence of the resident. The inspector was concerned that one of the risk assessments stated that a resident could accompany another resident to the shops whilst the placing authorities care plan clearly stated that staff should be present when out in the community. The manager demonstrated that this would be reviewed and discussed with all concerned and stated that the individual had not been out to the shops without staff support as yet. Risk assessments were being continually reviewed in light that some of the residents at Southmead Road were getting older. As part of this process the home has undertaken alterations to the property and installed aids and adaptations. Staff and residents spoke positively about the key worker role (named staff allocated to each resident) and the relationships that had developed. The manager stated that the residents had been consulted in the allocation of key workers. Residents spoken with gave many examples of how they were involved in the running of the care home, including recruitment, menu planning, activities, décor and attendance at resident’s meetings. Minutes of the meetings confirmed that residents were consulted and involved in making decisions. A resident told the inspector that they attend a forum organised by the Brandon Trust, which discusses wider issues. The resident and the staff saw these positively. One resident stated that they were involved in the recruitment of staff at Southmead Road but the organisation to their knowledge had not involved anyone with a learning disability in the process of the recruitment of Director of Services. It was evident that this had saddened them, as they had been involved in the past in recruitment of senior management. 384-386 Southmead Road Version 1.10 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Residents are encouraged to lead active and independent lifestyles, however this could be improved by the planning of more social occupation in the evenings and at weekends. EVIDENCE: Care plans included information on how the staff were supporting individuals to develop and maintain social, communication and emotional and independent living skills. The inspector saw that residents had been consulted on activities in the home. However, residents had requested to go ten-pin bowling but this had not happened since the original request in November 2004. Residents stated they would like more opportunities to go out but there is not always enough staff. The rota demonstrated that in fact whilst there was sufficient staff during the day only one member of staff works after eight in the evening which may inhibit residents going out in the evenings and the home has been heavily reliant on bank staff providing relief cover for a staff vacancy and a high level of sickness. This will be further discussed in staffing. 384-386 Southmead Road Version 1.10 Page 14 Residents stated that they were planning a holiday for later in the year to Butlins. Another resident described positive links with the church. Residents have a structured timetable from Monday to Friday. Residents were keen to share their busy week plan which included day centres, gardening groups and attendance at college. Staff described how they supported residents to choose how they wanted to spend their weekdays. One resident has retired but it was evident that they made full use of the community and was out most days visiting friends. A resident stated that they enjoyed watching the football and attended matches through the season. One of the residents uses makaton as their main form of communication. It was evident that whilst staff were getting by they had not received any recent training. Staff stated that the individual has developed their own specific signs to aid communication. It is recommended that staff document these signs and build up a communication dictionary, which could be shared amongst the staff team and bank staff. Residents described positive relationships with relatives and friends. Friends were invited to social gatherings and for evening meals. Contact included communication via Email to relatives abroad, telephone and in person. Residents stated that they were supported with transport to enable them to see their relatives. Residents confirmed they liked the food at Southmead Road and their involvement. A resident was aware of their special diet and confirmed that staff supported them. The menu demonstrated that the meals were varied and nutritious. 384-386 Southmead Road Version 1.10 Page 15 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) 18,19,20,21 Resident’s personal and health care needs are being met. EVIDENCE: Care plans described the support needs for individuals living in Southmead Road in relation to personal care. This included their preferences in relation to staff. Discussions with service users, staff and the manager demonstrated that the daily routine of the home is flexible to suit the individuals living in the home. Daily records and records confirmed this. The home is liaising with other professionals in the planning of the care ensuring a multidisciplinary approach, complimenting the skills of the staff team. Care records provided evidence that Residents had access to a doctor when required, dentist, optician and other health professionals. The home is in the process of introducing a new care-planning format for the monitoring of health care. This is good practice and demonstrates a commitment to meeting the targets of the government by introducing Health Action Plans for the individuals expanding on information previously held in the home. 384-386 Southmead Road Version 1.10 Page 16 The home has robust procedures and practices on the administration of medication, including a comprehensive induction and training package for staff. Training records demonstrated that staff have attended training on first aid, epilepsy and insulin. However, the training for insulin had not been updated in the last twelve months for four of the six staff. The home has guidance for staff to follow in the event of a death and residents have been consulted on their wishes. 384-386 Southmead Road Version 1.10 Page 17 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 have a robust complaints procedure, however, the policy on protection fails to meet the Department of Health Guidance. EVIDENCE: The home has a robust procedure for residents and their representatives to use in the event of a complaint. The home was able to demonstrate that complaints would be listened to and responded to in an appropriate manner. There is a requirement to ensure that the policy on the reporting of abuse is reviewed to ensure compliance to the Department of Health’s Guidance with the reporting of abuse called ‘No Secrets’. The policy in the home states that it is the decision of the director of services to make the decision whereas the ‘No Secret’s’ guidance states that this is the role of Social Services. The home has instigated an investigation using the Protection of vulnerable adults policy. An appropriate investigation and action has taken place. One member of the team has attended training on abuse. All staff must attend training on abuse to protect the residents living in the home. The home has good financial procedures to ensure the protection of resident’s finances. The home has responded to a recommendation that all financial transactions include two signatures. 384-386 Southmead Road Version 1.10 Page 18 384-386 Southmead Road Version 1.10 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 384-386 Southmead is a homely environment where consideration has been taken to meet the needs of residents with mobility issues, however, this must be extended. EVIDENCE: Southmead Road is situated close to shops, public houses, Southmead Hospital and there is a bus stop on the doorstep. The home is in keeping with the local community. The premises have been refurbished over the last two years to include provision of a bedroom on the ground floor and the installation of a stair lift. The premises externally were being painted on the day of the inspection. All bathrooms have been refurbished to a high standard enhancing the homely appearance. The bathrooms are accessible to residents that have mobility issues. However, the inspector noted that the path is uneven and in a poor state of repair and both the entrance to the front and rear of the property is inaccessible to residents who have mobility impairments as there is a step leading to the door. 384-386 Southmead Road Version 1.10 Page 20 All residents have a single bedroom, which is decorated to reflect their personal tastes. There is no call button installed in the home. This must be risk assessed and appropriate action taken to protect service users. A resident stated that they have to shout for staff when they require assistance to use the stair lift which can be difficult if they are in the other side of the building. The premises are comfortable bright and cheerful. Cleaning schedules were in place and the inspector found the home to be clean and free from odour. 384-386 Southmead Road Version 1.10 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 The home was unable to demonstrate that residents are protected by thorough recruitment practices, that the home is staffed to meet the social needs of the residents or that staff have the training to support individuals within the home. EVIDENCE: As already mentioned residents, staff and the manager stated that there has been a high use of relief staff to cover a staff vacancy and sickness. The manager could demonstrate that this was being addressed by the recruitment of staff. A new member of staff was planning to start the beginning of June 2005. The manager and Brandon Trust were addressing the sickness via the sickness and absence policy. Staff confirmed that a meeting had taken place. Whilst the home was adequately staffed the shift pattern did not blend to residents accessing the community with staff after the hours of eight in the evening. The manager stated that staff would be flexible if activities had been arranged. However, from reviewing the rota this was not a regular occurrence. From the duty rota it was evident that the home had a stable core bank team. Residents spoke positively about the relationships with some of the bank staff that worked in the home. 384-386 Southmead Road Version 1.10 Page 22 The inspector reviewed the training in place for staff, whilst it was evident that the manager was reviewing the health and safety training, inductions and the commitment to the Learning Disability Award Framework and staff completing the National Vocational Award. There were areas that had not been addressed namely protection of vulnerable adults training, insulin update and makaton training. These are subject to a requirement. Training records were incomplete. A member of staff stated that they had attended training on protection of vulnerable adults and this had not been recorded on their training record. From training records it was evident that staff were not attending 5 days training per annum (pro-rata for part-time staff) as per the National Minimum Standards. In addition the home has not responded to a requirement from the previous inspection to ensure that staff have the knowledge to support an individual with dementia. The manager stated that this was an oversight as he thought that the previous manager had arranged this training. The timescale has been extended to enable the home to demonstrate compliance. The inspector was unable to view staffing information as required under the Care Homes Regulations as this is held at the main office of Brandon Trust. Whilst the manager could clearly describe the process for robust recruitment procedures there was a lack of documentation to support this. This is an outstanding requirement since April 2002. Staff spoke highly of the support and direction from the new manager and the good communication that was in place. Staff stated that they have regular one to one supervisions. Records were seen confirming this. However, the manager has been in post since November 2004 and the staff have had only one staff meeting during this time. The manager stated that meetings have been difficult to plan due to the staffing and the high use of relief staff. This will be followed up at the next inspection. 384-386 Southmead Road Version 1.10 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42,43 Service users and staff benefit from an open culture of management. EVIDENCE: The home has been through a period of transition with a new manager starting in November 2004. Staff and residents spoke positively about the support of the new manager and his open management style. The manager is in the process of applying to become the registered manager and will be starting the Registered Manager’s Award in August 2005. a requisite of the role of registered manager. The home has a system for reviewing the quality of the care provision. This is good practice and informs the home’s business plan. The manager stated that the organisation is in the process of introducing a new quality tool. The inspector looks forward to viewing this on the next visit to the home. In 384-386 Southmead Road Version 1.10 Page 24 addition the organisation was visiting the home in line with the Care Homes Regulations. The Commission for Social Care Inspection were receiving copies of the monthly reports. The fire records were reviewed on this occasion, these were in order in relation to the training and the checks on the equipment. However, two staff had not participated in a fire drill within the last six months. Other systems to ensure the health and safety of staff and residents were in place including risk assessments, policies and audits on the premises and equipment. A training plan is in place to ensure that staff attend periodic updates on health and safety. The home has demonstrated compliance to a previous requirement to risk assess the storage of chemicals held in the home. The home introduced guidelines for staff and residents ensuring the safety of all concerned. The home has demonstrated compliance. All records relating to the running of the home were found to be in order. The home is commended on the accessibility of the care records and the resident involvement. The home must ensure that staff records held in the home are available for inspection. 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. Where there is no score against a standard it has not been looked at during this inspection. 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) 384-386 Southmead Road Version 1.10 Page 25 “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 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score 2 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 3 384-386 Southmead Road Version 1.10 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 14 Regulation 16 (2) (m) (n) Requirement To ensure that service users have opporunities to go out socially with care staff at least weekly to ensure that there is sufficent and competent staff to enable this to occur. For the organisation to review the policy on protection of vulnerable adults to ensure compliance to the Department of Healths No Secrets. For the records relating to staff as per schedule 4.6 to be held in the home. (outstanding requirement 11th September 2002) For staff to attend training in dementia care. (outstanding requirement since 14/1/04). For staff to receive an update in insulin. For staff to attend POVA training For staff to attend training in makaton. For the home to install a call alarm system. For the home to review the access to the home to include a ramp to the front and rear entrances and repair the path Version 1.10 Timescale for action 26/05/05 2. 23 13 (6) 12/08/05 3. 34, 41 17 (2) Schedule 4.6 18 (1) (c) (i) 18 (i) 13 18 (i) 23 (1) c (6) (1) c (2) (n) 12/08/05 4. 35 12/08/05 5. 6. 7. 8. 9. 35 35 11, 35 29 24, 29 12/06/05 12/11/05 12/08/05 12/07/05 12/07/05 23 (2) (b) (n) 384-386 Southmead Road Page 27 10. 3 Care Standards Act leading to the front door. In the interim this must be risk assessed. The home must apply for variation to include dementia (DE) to their certificate of registration for one named individual and to increase the age for another. 12/06/05 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. Refer to Standard 35 35 31 Good Practice Recommendations For staff to attend 5 days training per annum pro-rata for part-time staff Ensure that training records are up to date and in order. For the staff team to meet at least monthly 384-386 Southmead Road Version 1.10 Page 28 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 384-386 Southmead Road Version 1.10 Page 29 - 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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