Inspection on 28/11/06 for 384-386 Southmead Road

This inspection was carried out on 28th November 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

384-386 Southmead Road 12/02/06

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 Sarah Webb Key Unannounced Inspection 28 & 29 November & 5th December 2006 11:30 th th 384-386 Southmead Road DS0000026555.V319051.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 384-386 Southmead Road DS0000026555.V319051.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. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 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 www.brandontrust.org The Brandon Trust To be appointed 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.V319051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person with Dementia, over the age of 65. 12th February 2006 Date of last inspection Brief Description of the Service: Southmead Road is registered with the Commission for Social Care Inspection to provide accommodation 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 Brandon Trust operates the home that comprises of two adjourning properties that are 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 accommodated in single bedrooms. The home has one ground floor room. The home has installed a stair lift and adaptations to the bathroom to assist individuals that have mobility issues and those that are getting older. The home has a new manager who is presently completing the process with the Commission for Social Care Inspection to become the registered manager. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to review the progress to the requirements from the inspection in February 2006 and monitor the service provided to the residents living at Southmead Road. The inspection took place over 12 hours and was carried out as an unannounced inspection. The inspection methods used included record and documentation checks, case tracking, and discussion with three staff. Observation and discussion with a resident also took place. 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 new manager is in the process of being registered with the Commission. 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 was one vacancy at the time of the inspection. Since the last inspection all requirements bar 1 have been met. What the service does well: What has improved since the last inspection? What they could do better: 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 6 The organisation must take the necessary action to reduce traffic noise pollution in the home. This is forwarded from last inspection. The home needs to update both the Statement of Purpose and Service user Guide in order to provide appropriate information so that prospective residents can make an informed decision as to whether they wish to move to the home. The home must put arrangements in place for the monitoring of a residents night time activity inn order to keep them safe. The home must review and update residents care planning in order that staff support residents safely. The home must update resident’s healthcare records regarding their mobility needs and administration of medication, and hold a record of consent from residents for their medication to be administered. The home must improve in developing reactive strategies for those who are challenging and in providing training for all staff in the protection of vulnerable adults. The home is recommended to arrange for the environment to be reviewed by a suitable agency such as the RNIB in order that this resident is supported appropriately. The home needs to make repairs to a leaking toilet, replaster some areas of the kitchen and reallocate a space for a member of staff’s bicycle. The organisation must rectify faults on both boilers in the home. The home must update both staffing and training records with appropriate information. The home must ensure all staff attend both fire training and fire drills on a regular basis in order to ensure the health and safety of both residents and staff.0 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. 384-386 Southmead Road DS0000026555.V319051.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 384-386 Southmead Road DS0000026555.V319051.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 & 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User guide need to be updated in order that residents have adequate information to make a decision to move to the home. Prospective residents needs are assessed prior to moving to the home in order that the home can make a decision as to whether their needs can be met. Currently the home is able to meet the residents’ needs; however the home must ensure a resident’s needs are monitored regularly in order to demonstrate their needs can be continued to be met. EVIDENCE: The manager has updated the Statement of Purpose and the Service User Guide. The latter has been given to residents. Since the last inspection a resident has left the home due to their changing mobility needs and in the home being unable to meet these changes. The home has followed correct procedure involving a multidisciplinary approach in supporting the individual; the home has informed the Commission at each stage of their move to another home within the organisation. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 9 This has now left a vacancy at the home and the home is in the process of offering visits to a prospective resident whom the manager knows. Their needs have been assessed by their funding authority; the manager said the home would be able to meet their needs and that the move would be beneficial to the individual. The manager is in the process of dealing with residents changing their bedrooms. This is discussed in detail in Standard 25. If the room changes take place then the prospective resident must be informed in order for them to make a choice, through both the Statement of Purpose and the Service User guide, that the bedroom space they would be moving into is below the measurements as set out in Standard 25 of the National Minimum Standards. Currently this information is not included in either the Statement of Purpose or Service User Guide, therefore a requirement is made for both these documents to be updated. The Statement of Purpose also needs to include the new managers qualifications and those of the registered individual. 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. It was evident through observation and discussion with both the manager and staff, that there are several residents whose needs are changing in relation to both their age and mobility and the home is having to put in extra measures in order to meet their needs. One resident is in the process of being assessed by their funding authority due to significant changes to their health. Both staff and the resident have been supported by specialist services who specifically support individuals with dementia; staff have also received training in this area. The home is awaiting the outcome of the assessment as to whether they will be able to continue to support them. In the interim, the manager has used resources within the organisation to assist in carrying out a specific assessment; the resident underwent a respite placement within the organisation, due to Southmead Road not providing waking night staff. The respite placement monitored the individual’s night time activity in order to assess whether Southmead Road can continue to support their needs. The manager said the monitoring exercise confirmed that there were no night time activities from this person during their assessment period and that currently this is not an issue. The manager was unsure as to how this would be monitored at Southmead Road on a regular basis. The home must put arrangements in place for this to be monitored regularly in order to promote the individual’s health and safety and to ensure the home continues to meet their needs. 384-386 Southmead Road DS0000026555.V319051.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has care planning procedures in place; however the home must review and update some residents’ care plans in order that staff follow consistent practice. Residents are encouraged to make decisions about their lifestyles. The home must both review and further develop risk assessments in order that residents are supported safely. EVIDENCE: All 6 residents care files were examined. The home supports a person centred approach to residents care planning. Details included relevant history, preferences, making choices, communication, relationships, and daily routines. Although records indicated that care plans had been reviewed regularly, it was evident that some residents care planning is still in need of being reviewed due to their changing needs with information that was out of date. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 11 This relates specifically to two residents who need a consistent approach in being supported with both their mobility and other areas of living skills. One of the residents needs support in all areas of their life including personal care and individual support at meal times. A requirement is therefore made for the home to provide updated care plans for residents in order that staff can support them safely and appropriately in meeting their needs. Discussion with a resident and observation of daily records identified that individuals make decisions about their life from daily routines to choosing holidays. Residents meetings also give individuals the opportunity to discuss differing issues and make decisions in relation to general homely topics such as the menu. Risk assessments included supporting individuals in relation to outbreak of fire, health related issues, using the stair chair, vulnerability in the community and personal care. The manager is aware of the need for risk assessments to be updated and further developed regarding a specific resident whose needs have changed significantly. 384-386 Southmead Road DS0000026555.V319051.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): 12, 13, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a varied well balanced diet, and are supported and encouraged to live a fulfilling life. Their rights are respected and they are encouraged to take responsibility in their daily lives. EVIDENCE: Care records identified that currently there are 4 residents involved in attending appropriate day services during the week. This was demonstrated through individual timetables of social and therapeutic activities during the week. Two residents also attend college placements during term times. A resident spoken with said they enjoyed their varied day activities. They also said that they attended church on a regular basis. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 13 There are 2 residents who are not involved in external planned activities; one person manages their own time in accessing the community independently. This was observed during this visit when they went out to the local shops. They also they enjoy watching a local football club and attended matches through the season. The other resident is unable to attend a day service due to their changing health care needs and mobility issues; it was evident that staff have a good relationship with this person and were doing their best to support them appropriately in the home. Activities recorded included shopping, attending a tea dance and involvement with a regular social club in the evening. A resident said the majority of the home had recently been on ‘turkey and tinsel’ holiday at the seaside which they had enjoyed. One of the residents uses makaton as their main form of communication. The manager said a new staff member had a signing qualification and other staff had received training in Makaton. The manager is aware of this residents individualised signing and intends to build a photographic system of their preferred signs. Through discussion with the manager and observation of records it was evident that the home supports residents to maintain family contact. A written record is kept of meals offered; menus examined demonstrated that the meals were varied and nutritious with alternatives documented. A resident said they liked the food and was supported in making choices. The midday meal was observed, with one person requiring 1:1 support. The manager said that specialist services had given advice and instruction to staff in meeting this person’s specific meal time needs. It has previously been recorded in Standard 6 that care plans must also include information on how all staff should be supporting this resident with their meal times. 384-386 Southmead Road DS0000026555.V319051.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead healthy lifestyles with their healthcare needs being monitored. However, systems in place must be improved in order to provide additional and consistent information for staff to support residents safely. The home operates a robust medication system ensuring the safety of the service users. EVIDENCE: The home records all health related issues through two differing formats; both Health profiles and Health Action Plans describe the support needs of the residents living at Southmead Road in relation to personal care and individuals preferences, the administration of medication and other health related needs. Two residents are supported with their mobility, and it was evident that additional information must be provided in supporting them in this area and any manual handling requirements that staff need to be made aware of. Health profiles also provided evidence that residents have access to a doctor when required, dentist, optician and other health professionals. The manager 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 15 said that staff assist residents to book health related appointments and provide transport and support if needed. Records also identified that individuals’ physical and mental healthcare needs were being met through regular reviews of medication and support from appropriate professionals. It was evident that the home has comprehensive information in place relating to residents healthcare needs with the two differing formats providing the information. However there were some discrepancies in the consistency of information available and two residents record of medication administered in their Health Action Plans must be updated to run consistently with other health records and provide consistent information to staff. The home has robust procedures and practices on the administration of medication, including a comprehensive induction and training package for staff. Photographs of each resident are maintained in medication profiles with each record to ensure medication is dispensed to the correct person. Medication administration charts were up to date, and contained the signature of the staff, demonstrating resident’s medication is administered safely. Up to date records were kept of all medication being received into the Home and disposed of. A recommendation is made for a record to be held of the consent from residents for medication to be administered. 384-386 Southmead Road DS0000026555.V319051.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents have a robust complaints procedure that ensures individuals’ complaints are investigated promptly and thoroughly. Although the home has arrangements in place for protecting individuals from possible risk of harm or abuse and follows robust procedures, the home must improve in developing reactive strategies for those who are challenging and in providing training for all staff in the protection of vulnerable adults. EVIDENCE: There is an organisational complaints policy and procedure that indicates time scales to respond to complaints. It was evident through examination of the complaints log and further discussion with the manager that the home takes concerns and complaints seriously, that complaints are listened to and responded to in an appropriate manner. There have been two recorded complaints since the last inspection that have been dealt with appropriately. Discussion with a resident indicated that they are listened to regarding any concerns or complaints and that residents meetings take place regularly to discuss issues. There are appropriate policies and procedures through The Brandon Trust to ensure the protection of vulnerable adults. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 17 The home follows appropriate procedures in response to incidents relating to the protection of residents. It was evident through the examination of care files that the home has instigated an investigation using the Protection of Vulnerable Adults Policy. This involved appropriate agencies through a multidisciplinary approach. Training records indicated that 4 staff have been updated with information relating to the protection of vulnerable adults. A requirement is made for all staff to be updated with training in this area in order to ensure the protection of residents. Examination of care records identified that the home must develop written strategies in place for those residents who may challenge the service in order to protect both residents and staff. The home has suitable financial procedures to ensure the protection of resident’s finances. 384-386 Southmead Road DS0000026555.V319051.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, 25, 26, 27, 28, 29, & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home presents a comfortable, clean and homely environment, there are still areas that are in need of improving in both safety and maintenance so as to ensure the health and safety of residents. EVIDENCE: Southmead Road is situated close to shops, public houses, Southmead Hospital; there is a bus stop on the doorstep. The home is in keeping with the local community. All residents have a single bedroom, which is decorated to reflect their personal tastes. There is no call button installed in the home, but a risk assessment has been completed. As previously recorded in the text of Standard 3, the home must put arrangements in place for a residents night time activity to be monitored regularly in order to promote the individual’s health and safety and to ensure the home continues to meet their needs. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 19 The manager is in the process of dealing with both a request of a change of bedroom by a resident and a review of the suitability of current bedroom space for two specific residents. A resident who has a smaller bedroom has requested a bedroom change to another bigger bedroom. However the manager said that the current vacant bedroom space would be a more suitable bedroom for another resident due to their changing needs and believes this to be a priority in terms of their health and safety. This change would then initiate for a further resident to change their bedroom in meeting their mobility needs and having better suitable access to the stair lift. The Commission has received Regulation 37 reports in respect of this issue. If these changes are to be implemented, the manager said the resident requesting the change would still have the choice to move into another larger room, leaving their room vacant for the new prospective resident. As previously recorded, the home must then inform the prospective resident in order for them to make a choice, through both the Statement of Purpose and the Service User guide, that the bedroom space they would be moving into is below the measurements as set out in Standard 25 of the National Minimum Standards. A resident with a visual impairment has a bedroom on the ground floor. Although the home provides sufficient disability adaptations and equipment, a recommendation is made for the home to arrange for the environment to be reviewed by a suitable agency such as the RNIB in order that this resident is supported appropriately. The communal areas of the home were well furnished, light, airy and clean. The bathrooms are accessible to residents that have mobility issues. A leak coming from a toilet needs to be repaired. There are some small areas in a kitchen wall that is in need of being replastered. A conservatory is used as a smoking area for residents, however a bicycle belonging to staff is kept in this area and could impinge on both the residents’ privacy, and the external exit of this area in ensuring this is free from obstruction. The manager said due to the location of the home, the bicycle was stored in this area. Further discussion was had with the manager regarding the need for suitable alternative arrangements to be made for the bicycle to be kept safely. The home has two boilers that operate the heating. A boiler situated in the dining area must be repaired due to the front cover not fitting sufficiently. The other boiler is in the staff office, and also doubles as the staff sleep in room; the front cover is also not fitting and it was noted from the Gas Safety certificate that these faults had been identified at the last Gas Safety inspection but had not been rectified. A requirement is made these faults to be rectified by the organisation in order to ensure the health and safety of both residents and staff. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 20 Staff said it was often hot and noisy at night and the boiler was turned off. It was noted on the first day of this visit that the lounge was cold being due to the boiler not operating. The manager also had concerns about the close proximity of the boiler in the sleeping in room and whether this could be a health and safety issue. She was advised to contact the appropriate agencies responsible for the maintenance of the boiler and the organisational health and safety representative in following up these concerns. A requirement for the home to take necessary action to reduce traffic noise and pollution in the home is as yet unmet. The manager said this is in the process of being met; quotes have been obtained for replacement windows to be installed. A further requirement is made for this to be implemented. Cleaning schedules were in place for staff and the environment was clean tidy and free from odour. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from the clarity of staffs’ roles and responsibilities. The staff team have begun the process of obtaining a qualification in order to ensure residents are supported by competently. Residents are supported by the majority of staff being trained in appropriate areas; however the home must improve in keeping relevant documentation to evidence this. EVIDENCE: There are 6 staff employed to work at Southmead Rd; the majority of the staff team have worked at the home for many years. The home also uses bank staff to fill in for sickness, training and annual leave. Three members of staff were spoken with. Two of the staff are part of the longstanding team whilst the third had only just recently started work. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 22 All staff related their past experience and had a good understanding of their roles and responsibilities. The new staff member spoken with explained the induction they had received while the other staff identified individual residents needs and how they were met, and the ongoing daily procedures of the home. Two staff have a qualification in National Vocational Qualification level 2 whilst a further 3 are in the process of being enrolled. Staffing files identified that all necessary documentation was in place with regard to the recruitment process for the majority of staff. This included application, references, Criminal Records Bureau checks, and training attended. However, there was one specific staff file that is in need of being set up, including a training record and there are also some staff personal files in need of being updated with individuals start date. It was evident through observation of training records that several staffs’ mandatory training needs to be updated including food hygiene and First aid. These training courses have been booked for two staff. Additional training attended includes epilepsy and Makaton. Staff are also trained in supporting a resident with a specific medication and records indicated that an annual update takes place. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 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 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 adequate. This judgement has been made using available evidence including a visit to this service. There is a new manager in place who is in the process of being registered. The home has processes in place to review the quality of the service. The home needs to improve their practices of effective record keeping in order to safeguard the rights and interests of the residents. The home needs to improve measures in place to monitor the health and safety of staff and residents. EVIDENCE: 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 24 The new manager started in her post in May 2006. Ms Lea has previous experience within the organisation and has completed an application to be registered as the manager. She is in the process of completing both National Vocational Qualification Level 3 and the assessor’s award. Her training records indicated that she updates her knowledge and current practices regularly and has attended relevant training, including dementia, sexual health and relationships, person centred planning, and interviewing skills. The home has a system for reviewing the quality of the care provision through an organisational quality tool and reviews residents care on a regular basis. The organisation visits the home in line with the Care Homes Regulations. The Commission for Social Care Inspection were receiving copies of the monthly reports. Examination of differing records indicated that there are some areas that are in need of information being updated such as staffing records, residents’ valuables and training records. These have been recorded in the text of the appropriate Standard. Examination of the fire log indicated that not all staff have received annual fire training or have been involved in fire drills. A requirement is made both for all staff to receive regular fire training and to ensure by means of fire drills and practices at suitable intervals that the persons working in the home and so far is practicable service users are aware of the procedure to be followed in case of fire. A fire risk assessment had been reviewed and fire maintenance records indicated that fire equipment is inspected on a regular basis by both staff and contractors. 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 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 3 x 2 2 x 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA24 Regulation 23(1) Requirement The necessary action must be taken to reduce traffic noise pollution in the Home. This is forwarded from last inspection. Update both the Statement of Purpose and Service User Guide as set out in Standard 1. Put arrangements in place for the monitoring of an individuals night time activity. Review and update residents care plans. Update and develop risk assessments for an individual in relation to their changing support needs. Update residents healthcare records regarding their mobility needs and administration of medication. Develop reactive strategies for those residents who are challenging. Train staff in the protection of vulnerable adults. Repair leak to toilet. Timescale for action 31/05/07 2. 3. 4. 5. YA1 YA3 YA6 YA9 4 12(1) 15 13(4) 31/03/07 31/01/07 28/02/07 31/03/07 6.. YA19 17 31/03/07 7. 8. 9. 10. 11. YA23 YA23 YA24 YA24 YA24 13(4) 18(1) 23(2) 23(2)(b) 23(1)(a) 28/02/07 28/02/07 31/01/07 Repair/replaster areas of kitchen 31/03/07 wall. Reallocate space for staff bicycle. 31/01/07 DS0000026555.V319051.R01.S.doc Version 5.2 Page 27 384-386 Southmead Road 12. 13. 14. 15. YA24 YA34 YA35 YA42 23(2)(c ) Sched 3 17 23(4) Rectify faults on boilers. Update staff files with appropriate information. Update staff training records. Ensure all staff attend both fire training and fire drills on a regular basis. 31/01/07 31/03/07 31/03/07 31/03/07 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. 2. Refer to Standard YA20 YA24 Good Practice Recommendations Keep a record of consent from residents for their medication to be administered. Arrange for the environment to be reviewed by a suitable agency such as RNIB. 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 28 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 384-386 Southmead Road DS0000026555.V319051.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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