Inspection on 10/11/06 for 42 Barry Road

This inspection was carried out on 10th 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

42 Barry Road 23/01/06

42 Barry Road 15/06/05

42 Barry Road 30/03/05

42 Barry Road 08/02/05

42 Barry Road 02/03/04

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 42 Barry Road Oldland Common South Glos BS30 6QY Lead Inspector Odette Coveney Key Unannounced Inspection 10th November 2006 09:30 42 Barry Road DS0000003392.V318555.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 42 Barry Road DS0000003392.V318555.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. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 42 Barry Road Address Oldland Common South Glos BS30 6QY 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 9329705 0117 9329705 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Martin Rogers Care Home 11 Category(ies) of Learning disability (11), Learning disability over registration, with number 65 years of age (11) of places 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 11 persons aged 18 years and over. May include persons aged 65 years and over 23rd January 2006 Date of last inspection Brief Description of the Service: 42 Barry Road is registered to accommodate up to eleven active adults with learning difficulties, which may include people over the age of 65. The home is operated by Aspects and Milestones Trust. The home is on the edge of Oldland Common village within walking distance of shops, which include a post office, public house, chemist and other stores. The property is a Victorian detached house, which has been extended to create a large ground floor purpose-built area. The original building also houses a self-contained first floor flat which has the potential to be independent from the rest of the home for either a single person or a couple. All communal areas are on the ground floor and consist of a modern and spacious lounge with a partial glass roof with ten bedrooms leading off from this area. There is also a more traditional and comfortable front lounge in the older part of the building, a smaller lounge and a dining room and kitchen. The large and well maintained rear garden is fully accessible to service users. There is parking available to the front of the premises. The Home has a ‘mini bus’ to transport residents for necessary appointments and for leisure activities. 42 Barry Road DS0000003392.V318555.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 establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. The inspector spent a full day at the home on November 10th and returned to complete the inspection of November 15th. This inspection employed key elements of the national inspection methodology with the objective of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the manager on duty. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for four of the individuals were reviewed. Prior to the inspection a number of comment cards were received, these included three from individuals who live at the home, four from relatives of those who live at the home and a further nine comment cards from health and social care professionals. Feedback of the information provided to the inspector was shared with the manager during the inspection and have been incorporated within the body of the report. Individual’s identity has been protected to ensure anonymity. What the service does well: 42 Barry Road is a comfortable, environment in which individual’s live. The homes assessment processes and the information available about the home ensures that a placement is offered to those people whose needs they can meet. The homes care-planning processes will ensure that each person receives the care they need. Individuals indicated they were happy at the home and appeared well cared for. A number of comment cards were received from visiting professionals and relatives of those living at the home and some of these said that individual’s needs were being well met by a caring and supportive staff team. Relationships between individuals and staff are well established and effective methods of communication both verbal and non-verbal have been developed. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 6 It was clearly evident that the registered manager is committed to ensuring that all of the needs of individual’s at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individuals through a person centred individualised process. What has improved since the last inspection? What they could do better: In order to ensure that those living at Barry Road are fully aware of their rights and responsibilities in respect of their placement at the home it is required that all service users are provided with a copy or their terms and conditions of their placement, to include the arrangements for fees. In order that people are aware of the procedure to follow should they wish to make a complaint it is recommended that the manager considers ways of raising the profile of how to make a complaint to both relatives and health/social care professionals. In order to ensure that individuals needs are fully known and are being met it is required that the staffing levels required at night are monitored, that this is recorded and that any required changes are implemented. In order to ensure that individuals wishes and choices in the event of their death are respected and adhered to it is recommended that the home seek and record individuals wishes in this sensitive area. In order to ensure the safety of those living and working at Barry Road in the event of a fire, the home must ensure that equipment is safe and in order to demonstrate that staff are competent it is required that records of staff fire training records are maintained and that emergency lighting is checked as per the Avon Fire Brigade guidelines. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 7 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. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users individuals aspirations and needs are assessed, however not all service users are given full information about the terms and conditions of their placement. EVIDENCE: The home is registered to provide personal care and residential services for eleven adults, accommodating individuals over the age of 64. There is currently one vacancy at the home. There have not been any new admissions to the home for some time and therefore the process for new admissions was not fully discussed at this inspection. The homes statement of purpose and service users guide were not reviewed at this inspection as they had been evaluated at the last inspection, which was undertaken in January 2006. These documents were found to contained all of the required information in order that individuals can make an informed choice on whether the home is suited to meet their needs There are no individuals living at the home who are self funding. New service users are only admitted to the home on the basis of a full assessment of their need, this would involve the prospective individual. In line with the Trusts admissions policy. All individuals referred through the care management 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 10 process would have an assessment outlining their needs and would record how these are to be met by the home. During this inspection the care records for four service users were reviewed, two individual’s had a fully completed copy of their terms and conditions of their placement (licence agreement) and this document contained information about the ‘house rules’, how to make a complaint, what facilities and services are provided and a summery of the purpose of the home. One individual had no terms and conditions in place, the other persons document had not been fully completed and did not contain any information about the fee, and any other additional costs. A requirement was made that all service users must have in place a copy of their terms and conditions of their placement, that these documents must be explained to the service users and must contain full information in order that individuals are fully aware of the rights and responsibilities for themselves and the service provider. During the inspection staff were observed interacting with individuals, using appropriate language and tone of voice. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning documentation at the home contains clear, detailed information to enable individual’s personal, emotional needs to be well met, with individuals being supported and encouraged to make decisions that affect their life, EVIDENCE: The care documentation for four individuals were reviewed at this inspection; information seen included care plans, care plan reviews, health care support and social activities and inclusion. Since the last inspection the home has improved their recording of information contained within individuals files and the home has ensured that individuals ‘essential lifestyle’ information had been gathered and recorded. The information within individuals plan included; ‘how I communicate’, ‘how like to spend my day’, ‘things I would like to explore over the next year’, ‘things you need to know to keep me healthy and safe’, ‘things I prefer and the support I need to fulfil these’. Information is regularly reviewed and these documents provide clear guidance in order to support service users on a personal, individualised level. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 12 Information held for individuals was extremely detailed and it was evident that the information in place had been gathered over a long period of time; all of the individuals records had been written in a person centred way and had been tailored to the specific requirements of individuals. It was clear that information had been gathered through observation of individuals and that their preferred lifestyle had been well documented. Information recorded in care plans covered areas such as personal, physical, healthcare and emotional areas of support with guidelines in place to direct and guide staff practice. A requirement was made at the last inspection that the needs of the person disrupting sleep and mealtimes must be reassessed in order to decide whether the placement at Barry Rd continues to be appropriate or whether alternative staffing arrangements are needed to meet this person’s needs. Following a lengthy time period, involving other professionals, and a reassessment of this persons needs it was determined that Barry Road was not the most appropriate place for this individual and they have since moved. Service users are supported to take risks as part of a lifestyle to promote independence; information seen within assessments provided clear information on which decisions have been based. Action is taken to minimise risks and hazards and service users are provided with appropriate support to minimise identified risks and hazards; assessments seen included aspects of daily living, support with personal care and social and community activities. Records showed that assessments are reviewed and updated Records are stored safely and are able to be locked away. The home has a clear confidentiality policy that covers aspects of written and verbal information. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported to participate in activities of their choosing and to maintain relationships with their family. EVIDENCE: Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and individual plans. Staff enable service users integration into community life through knowledge and support to enable service users to make use of services, facilities and activities in the local community, such as shops, pubs, and places of local interest. Information seen by the inspector, and confirmed by staff and seen on individual’s records showed that those living at the home are offered a variety of social and leisure activities. Individuals are able to participate or not, this is dependent on the individual’s choice. Information seen in daily records evidenced that individuals regularly take part in the following activities such as; attendance at local community groups and clubs, church and shopping. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 14 Staff support individuals to maintain family links and friendships inside and outside of the home and this is facilitated by staff assisting individuals with correspondence, telephone calls and escorting individuals on visits to family members. Some discussion took place with the manager about opportunities for service users to develop and maintain intimate personal relationships with people of their choice. The manager was fully conversant with respecting the rights and choices of individuals and was able to demonstrate that the home would access specialist guidance if required in order to help service users make appropriate decisions and would be supported. On the day of the inspection one of the service users was participating in a meeting with their care manager, their family and staff members from the home in order to discus their care and the support provided at the home. Three members of the service users family spoke positively about the care and support their relative receives at the home, the said that their relatives health and emotional wellbeing ha improved, they commented that staff always made them welcome and kept them informed of areas of their relatives care. Prior to the inspection four comment cards were received from relatives of those who live at the home. All said that that staff welcomes them at the home and that they can visit their relative in private and that they are kept informed of important matters affecting their relative. Three of the four comment cards received recorded that they were not aware of the home’s complaints procedure, however none had ever had to make a complaint. All said they were satisfied with the overall care provided at the home. Additional comments included: ‘ I cannot express too strongly that the coping and kindness of staff has been wonderful’ and ‘my relative is very settled at the home and involved with several activities such as fitness, aerobics and an adult education centre’. At the last inspection it was recorded that the home should consider the use of a more appropriate vehicle, which would meet the increasing mobility needs of this ageing resident group. The home actively took on board this recommendation and the home now has a mini bus for service users use. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are well supported by staff and external agencies with all aspects of their personal, physical and emotional well-being. Legal requirements in respect of medication are appropriately met. EVIDENCE: Individuals had on their care files a personal care statement, which outlined the support they required with their personal care. Staff ensure consistency and continuity of support for service users due to having a designated key worker and also there is clear information recorded in care plans which sets out their preferred routine, likes, dislikes and communication methods. There was evidence of visits from the Doctor, occupational therapist, optician, chiropodist and other health professionals on the care files reviewed. A visitor spoken with said that their relatives see the doctor when they request it and confirmed support received from other health professionals. Records showed that individuals had attended hospital appointments when needed and were supported with any associated treatments. Recent correspondence from an 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 16 occupational therapist outlined that all avenues in respect of an individuals safety had been explored with aids having been provided. The opinion of this professional was that the service user would be safer if supported at night by staff who were awake. There was no information on the file to show that this had been considered. Mr Rogers said that he would respond back to the therapist to give his view on the suitability of waking night staff and the inspector saw a draft of this letter on 15th December, however it is required that there is an ongoing monitoring of the situation at night incorporating the support needs and safety of the service users to ensure that staffing levels are reflective of this. Medication administration, storage and recording procedures was reviewed, systems in place were found to be satisfactory. It was also noted at this inspection that clear medication policies were in place, there was evidence of receipt and disposal of medication and were properly recorded. Prior to the inspection four comment cards were received from relatives of those who live at the home, comments recorded included; ‘I cannot express too strongly the coping and kindness of all the staff who are wonderful to my relative’, ‘my relative has settled very well into the home, they have been involved with several activities such as fitness, aerobics and Kingswood Adult Centre, we feel our relative is very happy at the home’. Prior to the inspection nine comment cards were received from health and social care professionals who are or who have been involved with the support of individuals living at the home. All of these individuals took time to provide additional information and feedback about their view of the provision provided at the home. Comments included: ‘ I believe there are good members of staff working at Barry Road, but there are a dominant group who do not put service users first and act on their own convenience, this belief has been strengthened when I have spoken with other professionals who visit individuals at Barry Road. Time was spent with the manager and the comments and feedback given by health and social care professionals were discussed the manager said that he would have preferred it if individuals who had raised concerns had approached him directly in order to have dealt with the issues directly, he agreed with some of the comments that were made and agreed that the feedback would provide useful information to discuss with the staff team and look at ways of addressing these. It was also recommended that the home take a more proactive approach in obtaining feedback from others, see standard 22. Upon examination of care records it was found that not all service users had recorded what their wishes and choices are in the event of their death, due to the aging group of individuals who live at the home a recommendation was made that the home seek to obtain and record individuals wishes in order that these would be respected and adhered to. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 17 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear guidelines, policies and procedures in place to ensure that individuals are protected from abuse. Not all relatives, social and healthcare professionals are fully aware of the Trusts formal complaints procedure. EVIDENCE: Aspects and Milestones Trust have a clear complaints procedure in place at the home this includes the stages of, and timescales for the process and gives details of who to complain to. All service users had a copy of the organisations complaints procedure in their care plan the inspector during their visit. Of the four comment cards received from relatives of those who live at the home three were not aware of the homes complaints procedure. Of four comment cards received from social and healthcare professionals, feedback included; three said that they had received complaints from other professionals, and areas of concern raised were the apparent lack of communication between the staff team, healthcare guidance not being followed and manner of staff approach were discussed with the manager, see previous standard group. Following discussion with the manager it was recommended that home to consider ways of improving the profile of how individuals can make a complaint. The home maintains a record of issues and complaints raised by service users, the last recorded issues were in May 2006, the record detailed action and outcome. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 19 The organisation has in place robust policies and procedures for responding to suspicion or evidence of abuse or neglect, including whistle blowing. \Staff have received training in areas of adult protection, this is also incorporated when staff are undertaking their National Vocational Qualification in care practice. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 20 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, 28, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of furnishings and fittings in the home is good and overall a warm comfortable environment has been created ensuring individuals needs are met. EVIDENCE: 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 21 42 Barry Road is located within a residential area of Oldland Common. The home is in keeping with surrounding houses and close to local amenities and shops. The homes premises are suitable for it’s intended purpose, its accessible, safe and well maintained and meets service users individual and collective needs in a comfortable and homely way. The property is a Victorian detached house, which has been extended to create a large ground floor purpose-built area. The original building also houses a self-contained first floor flat which has the potential to be independent from the rest of the home for either a single person or a couple. All communal areas are on the ground floor and consist of a modern and spacious lounge with a partial glass roof with ten bedrooms leading off from this area. There is also a more traditional and comfortable front lounge in the older part of the building, a smaller lounge and a dining room and kitchen. The home was found to be well furnished with soft furnishings such as pictures, plants and photographs making for a homely environment. Communal areas for individuals use were found to be clean, tidy and odour free. Domestic staff are employed at the home and were seen working diligently on the day of the inspection A requirement was made at the last inspection that the home considers the use of a more secure arrangement for the side garden doors to ensure that residents do not wander onto the busy main road. The manager confirmed that security had improved in this area and that this would not be an area of concern. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 22 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): 33. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. benefit from competent staff that are trained and recruited in line with the organisation’s policies and procedures. EVIDENCE: Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individuals and have worked together with them and others in order to identify the needs of service users and then support the person in achieving their goals. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require. Regular staff meetings and team days are held at the home and appropriate subjects are covered in respect of the service provided at the home and are in line with the assessed needs of those living at the home. The manager confirmed that there are no staff providing intimate personal care for service users under the age of 18, and staff left in charge are over the age of 21. The manager also confirmed that staffing levels are regularly reviewed to reflect service users changing needs. A requirement was made at this inspection that the manager must keep under review/monitor the level of 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 23 support individuals require at night to ensure staffing levels are reflective of this. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 24 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, 38, 40, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and experienced staff team. EVIDENCE: Mr Martin Rogers is the registered manger of the home and has many years experience within the care profession. Mr Rogers has completed a National Vocational Qualification at level 4 in care management, is an assessor and an internal verifier for the NVQ process. Mr Rogers undertakes periodic training in order to maintain his knowledge and skills. Mr Rogers cooperated in the inspection process, and was able to locate all necessary information and documents easily. This evidences that the home has good systems in place and is well run. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 25 Team meetings are held on a regular basis and there was evidence that everyone is encouraged to make suggestions about how the run is run and what happens, staff spoken with also confirmed this. From talking with staff it was evident that they felt supported in their role by the manager. Information seen recorded from team events showed that management planning and practice encouraged creativity, development and change with new ideas being discussed, action planned and implemented. Mr Rogers had a good understanding of the care needs of the individuals. Positive relationships were observed between the manager, staff and the clients. Staff stated that the manager is approachable and operates an open door policy. The home has clear written policies and procedures, which comply with current legislation; these are readily available for staff. The inspector viewed the fire logbook for the home. The home was completing most of the required checks on the fire equipment, however improvements are required on the checks in respect of emergency lighting. The home must also improve on the record to demonstrate that staff has received sufficient fire instruction. At the time of the inspection it was found that the home did not have in place a fully comprehensive fire risk assessment. It was further noted that one client had their own risk assessment in place in the event of a fire happening at the home. When the inspector returned to the home on December 15th the manager had completed a fire risk assessment, linking this into individual identified risk factors, had recorded individual’s specific support and had also included what the procedure was to be at night. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 x 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X 3 X 2 X 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA42 YA42 YA33 Regulation 23(4) c 17(2) 18 (1) a Requirement Emergency lighting must be checked and these checks recorded. The home must maintain records of fire training, which has been undertaken. To keep under review/monitor the level of support individuals require at night to ensure staffing levels are reflective of this. Terms and conditions of the placement must be in place for all service users and contain all of the required information. Timescale for action 15/12/06 15/12/06 15/03/07 4. YA5 5(1) b 15/03/07 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 YA21 YA22 Good Practice Recommendations The home to seek and record the wishes of individuals in the event of their death. The home to consider ways of improving the profile of how DS0000003392.V318555.R01.S.doc Version 5.2 Page 28 42 Barry Road individuals can make a complaint. 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 29 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 42 Barry Road DS0000003392.V318555.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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