Inspection on 28/06/05 for 46 Bath Road

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

46 Bath Road 09/11/07

46 Bath Road 26/05/06

46 Bath Road 06/12/05

46 Bath Road 07/01/05

46 Bath Road 18/05/04

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 46 Bath Road Longwell Green South Glos BS30 9DG Lead Inspector Grace Agu Announced 28 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 46 Bath Road Address Longwell Green South Glos BS30 9DG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9601491 0117 9709301 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust Mrs Josie Bolt Care Home for Younger Adults 6 Category(ies) of LD Learning disability for 6 registration, with number LD(E) Learning dis - over 65 for 6 of places 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 6 persons aged 18 years and over. May include persons aged 65 years and over. Date of last inspection 7th January 2005 Unannounced Brief Description of the Service: 46 Bath Road is an older style Bungalow that was renovated about 7 years ago prior to becoming a Care Home. Access is via a private lane to the rear of the property. The home is located in a residential area of the most southerly aspect of South Gloucestershire. It is a quarter of a mile to the local shopping area of Longwell Green, other local amenities and post office. It is 4 miles from the City Centre. The home has a large lounge area, a spacious kitchen and a large general communal area. There are 6 bedrooms and sufficient toilet, bathing and sluice facilities are provided The small garden at the front of the property is not used and is currently maintained with a shingle surface. There is a large elevated grass area at the rear of the property and car parking space between this and the house. The home is a part of Aspects and Milstones Trust, a registered Charity providing residential Care for people with Learning Disability and Mental Health problems. The Home provides residential care for 6 adults with learning difficulties. The manager at the time of inspection was Josie Bolt. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place over eight and half hours and was undertaken to review the requirements made at the last inspection which took place on 17 January 2005 and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. The inspector undertook a tour of the building and viewed a number of records. Two residents and two staff members were spoken with on the day. Generally the home was found to be clean and airy. Residents looked well cared for and were found to be relaxed in their homely environment. What the service does well: Residents admitted to the home are fully assessed to ensure that the home is able to meet their needs and are receiving individualised care based on their care needs. The home consults existing residents before a new person is admitted to the home to ensure compatibility. Residents care plans are regularly reviewed and updated in line with their changing needs and residents are supported to take part in their chosen activities to minimise any risks that are taken, also residents are encouraged to have social links with the community and recreational activities available. The home provides nutritious meals for the residents. It supports them to have their meal and ensures that those residents who are not able to feed themselves are fed in a sensitive and dignified manner. The facilities at the home are adequate for providing personal care and to maintain privacy and staff are appropriately supervised to ensure that all care needs are met. The home has policy and procedure for the Protection of Vulnerable Adults available to ensure that residents are protected from abuse. Residents are supported to complain by staff members using the complaint policy, which is provided in a picture format. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3,4,5. The process of admission of prospective residents is detailed and well planned to ensure that the residents make a choice of moving to the home, with the assurance that their needs will be met. However the home fails to provide the resident with the Terms and Conditions of stay. EVIDENCE: The Home has a Statement of Purpose, which has recently been reviewed. The document contained information about the services provided at the Home. This document was forwarded to the Commission for Social Care Inspection after this inspection as required. The care files of newly admitted residents showed evidence of required assessment to ensure compatibility with other residents. The Manager stated that the existing residents were involved in the process of admission of the new resident. Residents were consulted and gave their consent before the new resident was admitted and the new resident who was transferred from one of the sister homes in Bristol owned by Aspects and Milestones visited the Home on three occasions to meet the ‘Ladies’ and stayed over night to ensure that she/he was given the opportunity to make a choice about whether to move into the Home. Two residents interviewed at the Home stated that they were aware and were consulted before the new resident “came to live with us”. The care file of the new resident contained care plans from the Bristol Care Management Team, the care file also had a comprehensive individualised care plan completed at the previous home. Staff spoken with at the Home 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 9 demonstrated knowledge of the needs of the new resident. Terms and conditions of stay were not seen in the care file. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10. Residents are supported to participate in making decisions at the home. Individualised care plans are followed and residents are confident that information about them will be kept confidential. EVIDENCE: Six care plans were reviewed and they contained person centred plans to reflect the changing and complex needs of the residents. The care files also contained other information to include next of kin and social and other health care support. Records noted on the care file include ‘About me’ this gives specific information about the resident, likes and dislikes, hopes and fears, valued options and relationships including speech and language therapy programme. The Speech and Language Therapist was visiting the home on the day of inspection to give advice about a resident with choking episodes. Other information noted in the records include care review notes. Staff were noted interacting with residents and one staff member spoken with stated that through body language and facial expressions staff are able to obtain consent or disapproval from a resident. Another staff member described a typical morning with a particular resident and how the resident is enabled to make choices. One service user spoken with stated that her key 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 11 worker supports her to plan recreational activities. The resident stated, “I go to Church on Sundays, I go to coffee mornings on Fridays and somebody from the Church comes to pick me up”. The resident stated that she helps out in the Home to lay the tables and water the plants when she is not shopping or visiting the club. There is evidence of residents meetings to include discussions about holidays, menus and proposed extensions to the building. One service user spoken with stated, “I am aware of the alterations to the Home and I am happy with that”. The care files viewed contained comprehensive risk assessments in place, which had been developed from using the individual care plan. The risk assessments seen included, “using the toilet, using the bed rails, accessing the community and manual handling. These risk assessments were regularly updated and reviewed. The Home maintains an individual daily diary for each service user. This diary is written from the resident’s perspective. In one resident’s diary the resident describes how she felt for the day, it states, “today I feel a lot better, I enjoyed my food and sat in the garden for a while”. Residents information and other records were noted to be securely locked away. One staff member spoken with demonstrated awareness of ensuring that all information relating to residents are kept confidential. The Home has a confidentiality policy. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17. Personal development is encouraged at the home, and support is given to residents to engage in leisure activities and maintain links with the community, family and friends. Healthy diet is provided for the residents at their chosen times ensuring that their individual rights are respected. EVIDENCE: Two care files reviewed had evidence that residents are supported to take part in local activities in the Community. One resident when spoken with stated that, “I attend Church on Sundays, I go to coffee mornings at the Church on Fridays, and that ‘somebody from the Church comes to pick me up”. This was recorded in her care file. Other activities noted on the file includes going to cinema, shopping for clothes and visiting friends. One care file reviewed contained evidence of daily and weekly activities to include attendance at Dover Court Road Day Centre five days a week. Another care file had evidence of planned beauty treatment at the local shop and day trips to Weston and Clevedon. The resident had previously visited Cheddar Gorge and Chew Valley café. Each resident had a daily diary written from the resident’s perspective, how they spent their day, what they found interesting 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 13 and what was most unhelpful. One resident was looking forward to going out for lunch with a volunteer from Age Concern on the day of the inspection. On the day of inspection, one service user was noted going out in the van with staff support to the shops, the service user told the inspector that, “I went out in the van yesterday with Caryl and I enjoyed it. Sometimes I help out in the Home to lay the tables and water the plants. There was a risk assessment in each care file for each resident’s activity in accordance with individual capabilities. Residents who were at the Home on the day of inspection were found to be relaxed in a positive atmosphere, one resident was noted accessing her/his room and office with a minimal of institutional rules and routines. Staff were noted communicating well with the residents. One staff member was noted taking a resident out on the patio and sitting down beside her and talking to her for a considerable amount of time. Another staff member was noted sitting on the chair in the lounge beside a resident with severe communication problems and talking to her and the resident was seen to be responding with grins and sometimes smiles. This was good practice and demonstrated that the staff team are inclusive. One resident was quick to show the Inspector the photographs taken at her 80th Birthday celebrations, which was well attended. Residents interviewed stated that staff respected their right to make a choice; one resident stated that she helps to plan the menu. The Manager stated that the menu is usually planned on Sundays with the residents, however, alternatives are offered to the resident if they change their mind on the day. Meals taken by residents are recorded in the daily diary to enable the staff to monitor resident’s food intake. Staff were noted supporting residents with their meals at lunchtime and those who were unable to feed themselves were fed with sensitivity and in a dignified manner. Finding a suitable job or training for the current client group would not be appropriate, however, the Manager and staff members are aware of the need to support the residents when it became necessary. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20,21. The residents receive preferred personal support as required, their emotional and physical needs are met, also respect is given to their wishes in the event of their death. However, the home’s medication practices fail to protect them. EVIDENCE: Care files reviewed showed evidence of how individualised personal care is provided for the residents. Personal care is provided in private and respects the dignity of the resident. One service user stated that staff treated her with respect and always knocked at the door and waited to be allowed in. One staff member spoken with gave a comprehensive account of how personal care is given to the resident with very complex needs. The staff member stated that she had worked at the Home for five years and knows the residents very well. The staff member ensures that the door is closed when providing personal care, speaks to the resident while providing personal care and ensures that the clothes are shown to the resident. The staff member stated that she knows that the resident likes “lots of sugar” and will close her mouth if there is not enough in her drink. The resident will let us know if she is not happy by her facial expressions and body language. The staff member stated that abdominal massage is performed on the resident daily as prescribed by the physiotherapist. This is recorded on the resident’s daily record sheet. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 15 The care files showed evidence of regular GP and other professional visits including reviews. On the day of inspection the Speech and Language Therapist was visiting a resident with choking problems and was seen interacting with staff in relation to the problem. Medication administration is undertaken by trained nurses and senior health workers who have received training from the dispensing pharmacist (Boots). A consent for self-medication administration of medication was noted on a resident’s file and a lockable cupboard is provided for safety of the medication. The resident stated that she holds her cupboard key all the time. Each resident had a photograph on the Medication Record Administration Sheet for identification. However, one resident’s sodium valporate prescribed by the Consultant to be given one tablet at night was not given for three days on 22nd, 23rd and 24th June 2005. The Manager was unable to give an explanation of why the medication was omitted but stated that she would find out from the staff on duty on those days. The Manager must ensure that medication prescribed for a resident is administered in accordance with the instructions. Staff demonstrated knowledge of how to treat residents when they are terminally ill and the procedure in event of death. The Home has a Death and Dying policy. All care files viewed showed evidence of risk assessments in relation to the care needs. One resident had a programme of abdominal massage; another resident with complex needs did not have fully completed risk assessment for the bed rails provided with the hospital bed, however, risk assessments in relation to using the equipment was provided for all transfers. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 22,23. The residents are enabled to complain with the confidence that their views will be listened to and acted upon, however, the home fails to protect them by lack of training of staff on abuse. EVIDENCE: No complaint was recorded since the last inspection. A complaint procedure written in picture format was noted in each resident’s file, which is relevant to the client group. One of the residents stated that she would complain to the Manager if she had any complaint. The training matrix provided by the Manager showed that three staff members have not received abuse training. One staff member interviewed confirmed that she had not received abuse training, however, stated that she is aware of how to recognise abuse and would report any incidence to the Home Manager. The manager stated one of the staff members was no longer working at the Home. The Home has a copy of South Gloucestershire’s policy and procedure for the Protection of Vulnerable Adults. All staff working at the Home have been checked by the Criminal Records Bureau and are satisfactory. Staff spoken with demonstrated awareness of the Whistle-blowing policy. There was evidence of property inventory in each residents file; this was regularly updated to include all new items bought by residents. Two residents’ monies were reviewed. One resident’s money in the purse was correct and balanced with the record. Another resident’s money was noted to be less than the balance recorded in the book. The Manager was unsure of the 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 17 reason why this had occurred because the resident went out shopping at the time of reviewing the money. A satisfactory explanation was sent to the Commission the next day from the Manager. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28,29,30. The home provides a homely and comfortable environment for the residents with specialist equipment, however it fails to provide a safe and hygienic environment for them. EVIDENCE: Major changes to the building had not occurred since the last inspection, however, it was noted that the room previously used for storage is being used as the Manager’s office to give way for the proposed changes at the Home. The Manager stated that the organisation has recently put in a planning application for four of the bedrooms to have en-suite facilities. There would be other changes to the lounge and the front door. These changes had been discussed with the residents. One resident told the Inspector that she is aware of the proposed changes and that she has no objections. The Home remains suitable for its purpose. The Home was found in a good decorative order, the communal areas and bathrooms were found to be clean, tidy and spacious to meet the residents’ needs. However, it was disappointing to note that the radiator on the hallway between the lounge and the bedrooms was noted to be sticking out with a 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 19 sharp end; this is considered to be unsafe for the residents and staff. A requirement was made at the last inspection for this to be removed or repaired, this requirement was not met. An Immediate Requirement was made for this to be repaired or removed immediately. The bedrooms were spacious and met the current standards, however, one bedroom had an unpleasant odour and the carpet required thorough cleaning. The dining room combined with the lounge was found to be clean, tidy, well lit and warm. This area was seen being used by residents for activities on the day of the inspection. Handrails and grab rails were noted around the Home and various hoists and equipment were seen to assist with residents mobility. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3132,33,34,35,36. Residents are assured that competent staff are recruited and supervised, however the home fails to protect them by providing insufficient training for its staff. EVIDENCE: Staff members spoken with on the day demonstrated knowledge of their roles and responsibilities. One staff member spoke with gave comprehensive information about a resident whom she assists as the key worker, the basic needs of the resident and how those needs were being met. One service user stated that she knows her key worker and was able to explain how the key worker ‘helps her’. Two satisfactory references, Criminal Records Bureau checks, record of qualifications were noted on the file of a newly recruited staff member. There was evidence of inductions in the two files viewed. There was evidence of staff supervision on the staff files viewed. This enables staff to ensure that resident’s needs are being met on an ongoing basis. On the day of inspection there were five staff from 7am to 3pm, two staff from 10am – 2pm, one waking staff from 9pm – 7am and one sleeping in staff from 1.30pm – 11pm and 11pm – 7am. Also, one staff 1.30 – 9pm. The Manager was working from 8am – 3pm. The Home currently has six service users. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 21 The staff training matrix provided by the Manager was reviewed. It was noted that staff have attended a range of training courses to include first aid, fire safety, moving and handling, food hygiene, Control of Substances Hazardous to Health and Vulnerable Adults. However, seven staff have not attended first aid training and three staff have not attended Vulnerable Adults training. The Manager stated that she would ensure that these staff receive training to ensure that residents are adequately protected. Four staff members have achieved NVQ 2 in Care, one staff member told the Inspector that she is currently undertaking NVQ3. The Manager stated that the Community Learning Difficulties Team (CLDT) is to provide training on a multi-disciplinary approach to Parkinson’s disease. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42, 43. The home is managed by a competent leader who safeguards the rights and best interest of the residents. The residents are protected also through comprehensive policies and procedures and record keeping. EVIDENCE: The Manager stated that she is still undertaking NVQ 4 in Management and has only three more units to complete the course. The Manager stated that she has currently completed a workshop on the new standards for assessing NVQ candidates. Staff members spoken with stated that the Manager is approachable and would listen to staff concerns in relation to their work. One resident stated that she is enabled to participate in the running of the home. She gave an example of helping to plan the weekly menu every Sunday. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 23 It was evidenced from discussions with the Manager and her interaction with staff and residents that she provides clear leadership and supports staff in their role to provide quality care to residents. Residents’ files and other relevant information were noted securely locked in the cupboards provided. Policies and procedures in relation to Health and Safety, adult protection, recruitment, whistle blowing, missing persons, complaints and manual handling were noted at the Home. The Home is making progress in the monitoring of the quality of its service. The Manager stated that Aspects and Milestones has developed a tool, which includes all the standards. The staff are paired to discuss the tool in relation to the residents care and other services provided at the home and the information is collated before issues identified are actioned. It is not clear how the residents are involved or how their views and the views of relatives, friends and visitors to the Home is ascertained. The Home is required to ensure that the quality assurance system is in place. Accident records were reviewed and it was noted that there was no follow up to show if the outcome of the accident was satisfactorily monitored. The fire logbook examined showed that the home ensures regular and satisfactory checks of all systems. Portable Appliance Testing was in date, there are recent Gas Safety and Electrical Wiring Certificates. Hoists and other equipments were regularly serviced. 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 46 Bath Road Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 2 2 D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 25 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. 2. 3. 4. 5. 6. 7. 8. Standard 30 42 42 39 43 5 35 35 Regulation 16 23 13 26 24 5 13 13 Requirement Ensure that a service users room is free from offensive odours. Ensure that all staff working at the home receive fire training. Ensure that the radiator in the hallway it repaired or replaced Provider visits are undertaken regularly to meet this standard. Ensure a quality assurance system that includes the views of the residents is used. Ensure that service users Terms and Conditions of their stay at the home are issued. Ensure that staff receive training on Abuse of Vulnerable Adults Ensure that staff receive training on First Aid Timescale for action 4/7/05 28/7/05 28/6/05 28/7/05 28/7/05 28/7/05 28/7/05 28/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 46 Bath Road D56 D05 S3384 46 Bath Rd V225341 280605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!