Inspection on 12/02/06 for 384-386 Southmead Road

This inspection was carried out on 12th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

384-386 Southmead Road 28/11/06

384-386 Southmead Road 11/05/05

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 Melanie Edwards Unannounced Inspection 09:30 12 February 2006 th 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 384-386 Southmead Road Address Westbury On Trym Bristol BS10 5LP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9504987 0117 9699000 The Brandon Trust Mr Daniel Peter Lloyd Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person with Dementia, over the age of 65. 12th May 2005 Date of last inspection 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. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. Four residents were consulted to find out their views of the Home, and what their experience of daily life is like. Part of the inspection was carried out through discussion with residents, and by observing staff carrying out their duties. The registered manager, and two care assistants were also consulted about their roles and responsibilities, training needs, and how they assist residents. A sample of records relating to the day-to-day running and management of the Home were inspected. Two resident’s care records and care plans were also reviewed. Lunch was also sampled in the company of residents at their invitation. The majority of the environment was viewed. What the service does well: What has improved since the last inspection? What they could do better: To benefit all residents action must be taken to reduce the effect from noise pollution from the extremely busy road outside the front of the Home. This road is clearly a very busy route at all times of the day and night. It is also next door to the local hospital, which generates further noise and disturbance for residents from the sounds from emergency service vehicles day and night. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 6 Resident’s medication stock would also be better protected if the Home were to monitor the temperature in the cupboard where medication is stored. This is to ensure medication is not stored above safe guidance temperatures. The Home must also obtain a metal lockable medication cupboard to be stored inside the medicine cabinet. This is for medication that needs to be stored securely. Two staff must sign for all medication to be returned to the pharmacist. This is to ensure there are safe systems for the disposal of residents’ medication. To benefit one resident, there should be written medication administration protocols to assist the resident in the administration of their medication. 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. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3, Residents’ needs are well met by the Home. EVIDENCE: Residents were observed being supported by understanding and sensitive staff. There was a warm and gentle humour when residents and staff were together and this was observed throughout the inspection. Residents looked very relaxed and comfortable in the company of the staff. All the residents who were asked were positive in their views of the staff and the care they provide by the service. Examples of comments made by residents included, `I go out in the day I like the food, and the staff are helpful,’ ` you can go out when you want,’ and, `it’s a nice house’. These comments were reflective of the views of all the residents who were consulted. To find out how residents care needs are being assessed two assessment records were inspected. There was a detailed assessment carried out of the resident’s physical, social psychological, and spiritual needs. The assessment information had been regularly reviewed and updated which helps show staff closely monitor residents’ changing needs. Residents need assessments and care plans are written from a `person centred perspective’. A `person centred perspective’ should further ensure that residents’ views and wishes are central when care needs are assessed. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 9 Residents are activity involved in the assessment process, and had signed care documentation in agreement with care to be provided. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 Residents needs are met and care plans also help to demonstrate how needs are met and monitored and reviewed. EVIDENCE: As referred to previously in the report, residents were observed being assisted by staff through the morning, and during lunch. Residents were being helped by understanding staff. The staff were also communicating well and there was a warm and friendly interaction between residents and staff. To find out about the way that care is being delivered one resident’s care plan was inspected. The care plan contained a range of helpful information, and demonstrated how to support the residents to meet their care needs. The care plans also addressed the resident’s psychological, and social needs, and stated how to respond and support the person if distressed. As has already been referred to in the report assessments and care plans are written from the perspective of `person centred planning’. This means residents help to identify what they feel their needs are, and how best they 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 11 think staff can help them. This should help ensure care is individualised and based on the active involvement and participation of residents. Residents are supported to take risks in their daily lives by staff. There were detailed written risk assessments, which helped to demonstrate actions are taken to ensure the Home is safe for residents and staff. Risk assessments also demonstrated residents are encouraged to live an independent and fulfilling life and take part in activities away from the Home. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,17 Residents are provided with a varied well balanced diet, and are supported and encouraged to live a fulfilling life. EVIDENCE: As was applicable at the last inspection, one resident told the inspector that they attend a forum organised by the Brandon Trust .The forum is to discuss a range of wider resident and service related issues. They also said that they had been involved in the recruitment of staff at Southmead Road. However according to the resident, the organisation had not involved anyone with a learning disability in the process of the recruitment of Director of Services. The resident concerned expressed their disappointment, as they had been involved in the past in recruitment of staff in the Trust. Residents have in place a timetable of social and therapeutic activities during the week. Some of the activities residents said they attend include day centres, gardening groups and attending a local college. One resident said they enjoyed watching a local football club and attended matches through the season. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 13 Two residents went out to church during the inspection. One resident said that staff assist them to get to the church every week. The lunchtime meal was sampled in the company of residents and staff. The meal consisted of roast lamb, roast potatoes, fresh cooked cabbage, carrots, broccoli and gravy. The meal was tasty and well cooked, and was nutritionally well balanced. All of the residents who were asked said they thought the meals served in the Home were very good. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents are supported to meet their needs in the way they prefer, and their medication is handled and administration safely. However the procedure for storage and disposal of resident’s medication is not fully safe. EVIDENCE: Residents care records included information that demonstrated residents have access to the GP dentist, optician and other health professionals. To support residents with their needs the Home liaises with other relevant professionals in the planning of care that is provided. This helps to ensure residents care needs are well met. Resident’s care plans included information about their personal care needs and the way they preferred their needs to be met. The procedures for the administration, storage, and disposal of medication were inspected with the assistance of the deputy manager, to monitor systems in place for handling medication. The medication administration charts of three residents were inspected in detail. There was a photograph of the resident maintained with each record to ensure medication is dispensed to the correct person . 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 15 The medication administration charts were legible, up to date, and contained the signature of the dispensing registered nurse, demonstrating resident’s medication is administered safely, the reasons for any omissions had also been written on the charts. Up to date records were kept of all medication being received into the Home. However the record of medication returned to the issuing pharmacy contained entries with only one staff signature. It was advised to better protect resident’s medication; two staff must sign for all medication to be returned to the pharmacist. This will demonstrate safe systems in place to monitor how much medication is returned by the Home. It was noticeable that the staff office used to store resident’s medication, felt warm in temperature. It was advised that the Home should monitor the temperature in the cupboard where medication is stored. This is to ensure medication is not stored above safe guidance temperature. One resident’s needs are changing due to changes in their health. This was discussed with the registered manager because this has affected the persons ability to take their medication when administered by staff .It was advised that written medication administration protocols would assist the resident in the administration of their medication. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents are protected by the complaints procedure, which helps ensure complaints are investigated promptly and thoroughly. Residents are also protected from harm or abuse. EVIDENCE: A copy of the complaints procedure for resident’s to make a complaint is on display in the dining room. This is a well-frequented part of the Home. The complaints procedure has been written in a user-friendly pictorial format to assist the reader. The procedure includes the contact details for the Trust and the Commission for Social Care Inspection. The complaints record book was viewed to find out how the Home responds to complaints. There had been no new complaints recorded since before the last inspection. The record did include the details of how the complaints were to be dealt with and the timescales for completion. All the residents who were consulted said they felt very able to speak to any of the staff if they had any concerns or complaints. There are also regular residents meetings held. This is an opportunity for residents to express any concerns or complaints they may have. Two residents said that there was a residents meeting due to take place later in the day, and they said they thought the meetings were important. This should help create a culture where residents feel `comfortable’ to complain. There are policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. Since the last inspection all staff have attended training on the issue of `protection of vulnerable adults from abuse’. This 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 17 should help ensure that residents are safeguarded from the risk of harm or abuse. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Residents live in a homely environment that generally meets their needs. EVIDENCE: Southmead Road is situated close to shops, public houses, Southmead Hospital and there is a bus stop on the doorstep. The premises have been refurbished over the last two years to include a bedroom on the ground floor and the installation of a stair lift. All bathrooms have been refurbished to a satisfactory standard giving a homely feel to the rooms. The bathrooms are accessible to residents with limited mobility. Bedrooms are all single occupancy. Rooms were decorated to reflect residents’ different personal tastes and interests. At the last inspection it was observed that there was no call button installed in the Home. This has now been risk assessed and appropriate action taken to protect residents. There is currently a monitoring system in use for two residents’ rooms, although the manager reported that one resident had required the monitor should be removed from their room. This had been carried out to respect their wishes. The Home felt `light’ and airy in communal rooms and bedrooms. The environment was clean tidy and free from odour. However the Home is located on a road, which is clearly a very busy route at all times of the day and night. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 19 It is also next door to the local hospital, which generates further noise and disturbance for residents from the sounds from emergency service vehicles at any time of day or night. Three residents said how unpleasant and disturbing they found the continual noise from the road and from emergency services vehicles. The inspector could also hear the sound of traffic inside the Home that was clearly noisy. To benefit all residents action must taken to reduce the level of noise pollution from the busy road. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 Residents are supported to meet their care needs by competent wellsupervised staff. EVIDENCE: The staff duty record for shifts worked for the previous month was inspected to review the number of staff on duty to support residents with their needs. There is a minimum of one member of staff on duty for a night shift, and between two and three staff on duty during core hours during the day between 10am and 5.30pm to work closely supporting residents both in and out of the Home. The training records demonstrated staff had attended training courses and study days relevant to the needs of the residents. Based on the positive comments made by all of the residents who were consulted staff evidently support residents sensitively. Staff also reported that the manager provides them with regular structured supervision sessions to assist them in their work and best understanding their needs. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41,42 The health and safety of residents’ staff and visitors is protected and generally the Homes record keeping helps to safe guard resident’s confidentiality. EVIDENCE: Records are kept in the office and this room is kept locked when not in use ensuring residents confidential information is held securely. All the records inspected were well maintained, up to date and in order. Other records have been referred to elsewhere in this report, and demonstrate wellorganised management in the Home. The environment looked satisfactorily maintained throughout. However please refer to previous comments made in the report about the noise pollution that effects residents from the busy road and the hospital next door. There are health and safety procedures in place for staff and residents to follow to promote health and safety in the Home. All staff attend regular health and safety training provided by The Brandon Trust to better help them protect residents. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 22 The fire logbook record showed that the range of required fire safety checks were being carried out and were up to date helping to ensure the safety of people inside the building is maintained. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 384-386 Southmead Road Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score X X X X 3 3 x DS0000026555.V261884.R01.S.doc Version 5.0 Page 24 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 YA20 Regulation 13. (2) Requirement Monitor the temperature in the cupboard where medication is stored to ensure medication is not stored above safe guidance temperatures Obtain a metal lockable medication cupboard to be stored inside the medicine cabinet. Two staff must sign for all medication to be returned to then pharmacist. The necessary action must be taken to reduce traffic noise pollution in the Home. Timescale for action 13/02/06 2 YA20 13. (2) 12/03/06 3 4 YA20 YA24 13. (2) 23.(1) 13/02/06 12/07/06 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 YA20 Good Practice Recommendations There should be medication administration protocols in place for the resident identified at the inspection. 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 384-386 Southmead Road DS0000026555.V261884.R01.S.doc Version 5.0 Page 26 - 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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