Inspection on 09/11/07 for 46 Bath Road

This inspection was carried out on 9th November 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Bath Road 26/05/06

46 Bath Road 06/12/05

46 Bath Road 28/06/05

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 Key Unannounced Inspection 9 and 21st November 2007 09:30 th 46 Bath Road DS0000003384.V347670.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 46 Bath Road DS0000003384.V347670.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. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Bath Road Address Longwell Green South Glos BS30 9DG 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 9601491 0117 9709301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Bibi Affroze Bahadoor Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 18 years and over. May include persons aged 65 years and over. 26th May 2006 Date of last inspection 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 Milestones 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 Bibi Affroze Bahadoor. Fees range from £1052.00 per week. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was undertaken over two days to review the care practice to ensure that it is in line with legislation and that best practice is followed at the Home. The inspection also followed up the action the home had taken to ensure that the last inspection requirements were met. The Home was found warm, well lit, clean and free from unpleasant odours on both days. People living in the home were found relaxed and looked well cared for in their homely environment. The Manager was unavailable on the first day of the inspection however staff met on duty professionally assisted and cooperated with the inspection process. Whilst touring the building, staff were noted interacting with the residents in a dignified, friendly and sensitive manner. Information about care of the individuals living in the home and the services provided at the home were obtained through review of records, including policies and procedures, care files, staff training and staff recruitment. We met with the Ms Affroze Bibi Bahadoor on the second day also and spoke with people who use the service and a small number of staff. What the service does well: When we looked at the records of the people living in the home we noted that individuals 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 service users before a new person is admitted to the home to ensure that the can live with them. It was evident from the staff interaction with the residents’ and the records seen that there is a warm relationship between the staff and the residents at the home. People living in the home have care plans, which are regularly reviewed and updated in line with their changing needs. Individuals living in the home are supported to take part in their chosen activities to minimise any risks that are taken, also people living in the home 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 6 are encouraged to have social links with the community and to take part in recreational activities available. The home provides nutritious meals for the people living in the home. It supports them to have their meal and ensures that those people 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. Evidence shows that staff are adequately trained and developed and are appropriately supervised to ensure that the needs of the individuals living at the home are met. The home has policy and procedure for the Protection of Vulnerable Adults available to ensure that the people are protected from abuse. People who use the service are supported by staff members to complain using the complaint policy that is provided in a picture format. To further help us make judgement about the services provided at the home we sent comment cards to the relatives of people who use the service and also people from the outside who visit the home for various reasons. The comments they sent to us are written below: “An excellent home. I always feel that it is a home not an institution. Staff have obvious respect for the residents and only make an appointment or contact us when appropriate”. “I never thought that my relative would have such a social life which frequently involves myself”. “People who use the service are kept clean and tidy and all carers see that the individuals are dressed to their own particular fashion. Those carers show great love and devotion even their rooms suit their personality. The relationship between the people who use the service and the carers is a happy one and all their needs are considered at all times.” What has improved since the last inspection? The manager told us in the Annual Quality Assurance Assessment that as needs of people who use the service increase the home seeks support from relevant professionals. All staff have completed a medication competency training pack (carried out by the home manager/ assistant home manager). 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 7 Staff receive more regular supervision to enable them to discuss training and development needs in relation to meeting the needs of the people who live in the home. At the last inspection, a requirement was made in relation to ensuring that staff records must be available at the home for inspection at all times. It was pleasing to note that one file viewed in relation to a new staff member contained evidence of a Criminal Bureau Record disclosure (CRB) and other evidence of satisfactory recruitment documentation before the individual commenced employment in early July 2007. 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. The summary of this inspection report can be made available in other formats on request. 46 Bath Road DS0000003384.V347670.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 46 Bath Road DS0000003384.V347670.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): 1,2 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The process of admissions of prospective residents is detailed and well managed to ensure that residents make positive choice of moving to the home with assurance that their needs will be met. However the home fails to review the information on the Statement of Purpose and the Service Users Guide for the benefit of the prospective and existing service users. EVIDENCE: There have been no new admission to the home since the last inspection and most of the individuals have lived together in the home for several years. The manager stated that residents would normally be assessed and encouraged to visit the home on a trial basis to ensure he/she is happy to stay and that the person is compatible with the existing residents. One person’s care plan viewed evidenced measures in place to meet specific assessed needs, staff members that we spoke with on the day were aware of their roles and responsibilities and how to support all individuals living in the home to meet their needs. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 10 The home has a Statement of Purpose and a Service Users Guide, which has information about the services provided at the home. For example how to make a complaint and any support that would be given in relation to the individuals’ health. However these two documents have not been reviewed to ensure that accurate information is given to prospective and existing service users. A requirement was made for the documents to be reviewed and a copy forwarded to the Commission for Social Care inspection. This information was received at the Commission before this report was completed. Each resident had a license agreement in the care file; this document was written in a picture format and contained fees to be charged. The inspector noted that the documents were signed by the peoples’ representatives. 46 Bath Road DS0000003384.V347670.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: Two care files were reviewed and they contained person centred plans to reflect the changing and complex needs of people using the service. The care files also contained personal information to include next of kin and social and other health care support. The care records reviewed contained comprehensive information focused on the specific requirement of the individual. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 12 Records noted on the care file contained information to include ‘About me’ this gives specific information about the person’s, likes and dislikes, hopes and fears, valued options and relationships including speech and language therapy programme. Other information noted in the records include care review notes and the details of how staff can interpret the non-verbal communication of the resident and more importantly when the resident is unhappy or dissatisfied with any aspect of the services or their care. Staff were seen adding and referring to the care records during the inspection demonstrating that they are using the documents as a working tool as expected. Staff were also 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 service user. 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 worker supports her to plan recreational activities. The resident stated, “I go to Church on Sundays, I go to coffee mornings on Fridays”. 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 bath, using the bed rails, accessing the community and manual handling. These risk assessments were recently updated and reviewed. However we noted that one individual using a hospital bed with bedrails had no evidence of consent to confirm that they were consulted before the bedrails were installed. The manager told us that relevant health professionals and the home made the decision and that the individual was informed. This was not documented. It was agreed that the home obtain consent from this person to ensure that their right to make a decision is not compromised. This consent has been obtained. The Home maintains an individual daily diary for each individual. This diary is written from the resident’s perspective. For example in one individual’s diary the person describes how she felt for the day, “I enjoyed the coffee morning today”. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 13 The manager told us that the people living in the home are supported to attend regular house meetings and the notes of the last 2 meetings were seen to include discussion about holidays, food, visits and staff and the inspector gained the clear impression that every thing that occurred in the home was done with the involvement of the people who use the service. Service users information and other records were securely locked away. One staff member spoken with demonstrated awareness of ensuring that all information relating to people who use the service is kept confidential and what actions to take in the event of a breach. The Home has a confidentiality policy. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 14 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. People who live in the home are encouraged and supported to engage in leisure activities and maintain links with the community, family and friends. Healthy diet is provided for the individuals at their chosen times ensuring that their individual rights are respected. EVIDENCE: 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 minimum of institutional rules and routines. Staff were noted interacting with residents in informal, however, sensitive and respectful manner. This is a demonstration of good practice and shows that the home includes the residents in the daily routines. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 15 One staff member interpreted some of the non-verbal expressions used by one individual during the inspection to express her disapproval that the inspector sat on ‘her chair’. This is commendable. It was evident from discussions in the home that service users are encouraged to participate in and generally to enjoy and benefit from recreational resources in the local community. The wishes and needs of the service users are regularly reviewed. There are current arrangements to support one individual to attend the regular visits four days a week for activities at Dovercourt Day Care centre This gives valued one to one support to the individual in a relaxed environment. Two of the service users enjoy visits to the local church for coffee mornings and general recreation. On the day of inspection, one resident told us that she was scheduled to go out with support from a previous staff member but the individual was on holiday the home rearranged for her to accompany another individual to visit Age Concern facilities for lunch. One staff member told us that this is to ensure that the individual fully participates in a daily activity without missing out on the day. Other activities noted at the home included Bingo, cinema, shopping and visiting family. One resident stated that she recently went on holiday to Bognor Regis where she used to live and also to see her family. Key workers are currently supporting the service users to maintain daily diaries. This helps to focus on the days activities and to plan ahead. An example of the daily dairy states that the individual attended the 21st birthday party for the Trust on 2/11/07 and when spoken with stated ‘I really enjoyed my self’. It was evident that the staff are sensitive and supportive to the continuance of family links and other friendly relationships and this contributes to the general state of wellbeing for two of the people who use the service. One comment card we received from a relative confirms the above observation. It stated, “I never thought that my relative would have such a social life which frequently involves myself”. Evidence from the visitor’s book showed that residents were visited regularly. For other service users the contacts and relationships they have are associated with the home and are all important and it seems staff are sensitive to this also. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 16 The printed menu detail was provided for 2 weeks. This appeared to be particularly nutritious or varied and it did appear that all the appropriate nutritious elements of a balanced diet are being provided each day and on a weekly basis. Staff stated at a discussion that individuals using the service are supported and encouraged to participate in planning the menu for the week however, if anyone changes their mind, alternatives are always available. The presentation of the lunchtime meal on both days was very appetising. Clearly there is evidence that staff make considerable effort to meet the individual nutritional needs based on their likes and dislikes and their variable abilities to eat. For example the inspector noted that staff were supporting those who were unable to feed themselves in a sensitive and dignified manner. We reviewed the care file of the individual that the relative was concerned about their weight loss. We found that the General Practitioner (GP) and the dietician regularly reviewed the person. The individual is encouraged to eat normal meals alongside high protein and high calorie drinks prescribed by the dietician. Records show that the individual’s weight was being monitored on a weekly basis and the individual had gained three pounds since the last recording. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 17 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. Residents receive preferred personal care as required, their emotional and physical needs are met, also respect is given to their wishes in the event of death. The home’s medication practices offer adequate protection to the people who live in the home. EVIDENCE: People who use the service all have their own rooms that they are able to arrange as they wish and use at any time. There are two linked areas of communal space, the largest of these is used mostly and provides lounge and dining space. As mentioned previously, two care files viewed contained individualised care plans detailing how the residents assessed needs are being met. The care files also provided staff with information on actions to be taken if they were exposed to challenging situations. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 18 The manager stated at a discussion that staff attend to each individual’s personal needs based on their preferences and choice. For example a particular individual is assisted to get up late morning on Mondays because it is the person’s day off from attending Day Care services. There was evidence that staff are aware of how to contact the General Practitioner (GP) if any of the individuals became unwell and would contact the emergency services if urgent treatment were required. Staff used their professional skills and experience to attend to two residents with complex needs without undermining the residents’ independence. Staff were noted knocking at the doors and waiting for answer before entering to attend to residents in their individual bedrooms to ensure privacy and dignity is maintained. Medication administration was reviewed and was found satisfactory. There are individual medication profiles for each service user recording their consent and preferences for taking medication, and details of the prescribed drug for reference. Where an individual had a specific medical condition, for example the likelihood of seizures, written guidance was provided on how to administer the medication and to get medical help or contact ambulance services. The Medicine Administration Record Sheets (MARS) are computer generated by the dispensing pharmacist. Records are in place for the receipt and disposal of drugs. Staff have attended Medicine Administration Competency Training. Concerns regarding the numbers of drug errors that occurred in the home since the last inspection was discussed with the home manager. The following measures have been put in place to prevent further occurrence. They include: Review of the drug policy, checking the blister packs and MARS by two staff members on taking over in the morning and change of shifts signing the confirmation sheet that everything is satisfactory, Medication Competency Update for all staff, training from the dispensing pharmacy (Boots) and Trust medication training. The home has a death and dying policy and staff demonstrated awareness of how to care for people living in the home in the event of any change of circumstance or death. The care plan of one individual contains clear information about the person’s wishes, choices and decision in the event of her death. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 19 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. The residents are enabled to complain with the confidence that their news will be listened to and acted upon. There are systems in place to protect individuals living in the home from abuse. EVIDENCE: No recorded complaints were noted in the complaints book since the last inspection. There is a complaints procedure in a picture format in the residents’ care files reviewed. It was agreed that the information about the Commission for Social Care Inspection be updated with the current address and phone number to ensure that the service users and their relatives have accurate information if they wanted to contact the Commission for any concerns. One staff member interviewed gave a detailed description on how a particular person expresses dissatisfaction with any staff member or services. The individual would use her facial expression to indicate whether she is happy or not. This enables staff to explore the reasons the person is in that mood and act on it to put the situation right. There is a copy of the South Gloucestershire Policy and Procedure for the Protection of Vulnerable Adults alongside Aspects and Milestones Policy noted at the home. There is also a Whistle Blowing Policy to enable staff to report any bad practices without the fear of reprisal. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 20 The manager demonstrated knowledge of the procedure for reporting incidents of abuse if they occur. Staff members have received training on Protection of Vulnerable Adults and staff interviewed demonstrated awareness of how to report incidences of abuse. New staff working at the home have satisfactory Criminal Record Bureau disclosure to ensure that residents are adequately protected. All serious accidents and notable incidents are reported to the Commission using the Regulation 37 Notification form. One individual with bedrails installed on the hospital bed for safety had a risk assessment in place. This was previously discussed in standard 7. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 21 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 26,27 29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents are provided with a good comfortable environment with suitable specialist equipment where they feel safe to live, however the home fails minimise hazards in some parts of the home. EVIDENCE: No changes had occurred in relation to the home’s suitability for its stated purpose. Residents were found sitting in the communal area and appeared relaxed in their homely environment. One resident was noted accessing the communal area, kitchen and their individual rooms, also interacting with staff in an informal way. The premises were generally clean tidy and free from unpleasant odours. There are arrangements in place to dispose of clinical waste. The home has a comprehensive policy on Infection Control provided by the Trust to ensure that people living in the home and staff and visitors are protected. The laundry area was found clean tidy with good flooring and ventilation. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 22 The manager stated at a discussion and this was confirmed in the home’s Annual Quality Assurance Assessment (AQAA) sent to the Commission that two persons rooms have been redecorated and the flooring replaced to provide easy movement of handling equipment. One of the individual’s relative was involved in the selection of the décor and choice of the flooring due to the service users profound learning disabilities. However the carpet in one of the service users room was noted with stains and needs to be deep cleaned or replaced. A requirement has been issued for this to happen. We also noted whilst touring the environment that the handling equipment in the bathroom had flaking paint with rough edges on both legs. This is potentially hazardous to the safety of the service users. The manager stated that new handling equipment had been ordered and that the home is awaiting its’ delivery. A requirement has been issued to ensure that this piece of equipment is repaired or replaced. Staff spoken with were aware of safe practices necessary to prevent the spread of infection should it occur. It was agreed that generic risk assessment must be undertaken to include the laundry area to provide adequate protection for the people living in the home, staff and visitors. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 23 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): 32,34,35,36. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users are supported by a competent and effective staff team and are protected through appropriate staff supervision. EVIDENCE: Discussion with manager and evidence from the newly employed member of staff show that appropriate recruitment procedure was followed. The file contained two satisfactory references, record of identity and a letter confirming that the Trust obtained satisfactory Criminal Record Bureau (enhanced) disclosure before the staff member commenced employment. According to staff training records, there has been regular training updated to include, Fire Safety, Moving and Handling, Food Hygiene, First Aid and Health and Safety. On the day of inspection, there were adequate numbers of competent staff on duty to meet the complex needs of the individuals living in the home. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 24 Staff records viewed evidenced that staff are receiving regular supervision to ensure that all areas in relation to the roles and responsibilities are appropriately addressed to meet the needs of the people using the service. The manager stated that there are regular house meeting to discuss issues of interest to the service users and the home in general. Record of the last meeting evidenced that shopping, using bank staff for emergency medication and fire drill were discussed. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 25 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): 37,39,42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home benefits from good leadership and management, its practices fully protect the health and safety of the individuals living in the home. EVIDENCE: Ms Bibi Affroze Bahadoor is a competent Manager and has been at the home for about 18 months. Ms Bahadoor has completed Registered Managers Award and has attended many other courses to include Vocational Assessors Award D32, D33, and Mental Capacity training Managing medicines to enable her to support staff members in delivery of along of care to the people using the service. Staff spoken with made positive comments about the manager’s ability to manage the home with this service user group. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 26 Residents were unable to make comments about the Manager due to their level of understanding and communication difficulties, however it was obvious that there is a good warm relationship between the Manager, residents and staff through the interactions noted on the day of inspection. The inspector noted that the Trust has developed a quality audit tool with the Commission for Social Care Inspection focusing on the outcomes for the people who use the service based on the National Minimum Standards for different services. It was unclear whether this document had been used in this service. Other ways used to audit the service include the provider’s monthly visits and reviewing the Care Plans monthly. Staff training is also reviewed to ensure that appropriate training is provided to meet the residents needs. It was agreed that the home consult relatives, friends and other health professionals for a feedback about the services provided at the home. The accident book was reviewed and it was noted that accidents are satisfactorily recorded and followed up and it was agreed that the risk assessment must be reviewed after each accident to minimise incidents of falls. The fire logbook was reviewed and was well maintained, staff have attended regular fire drills to enable staff to become familiar with measures to be taken in actual fire emergency. The Manager stated that generic risk assessments of the home will be undertaken and she would ensure that individual risk assessments in relation to residents’ rooms would be undertaken and included in their files. Other measures in relation to resident’s health and safety to include maintenance of fire alarm systems, smoke detectors, emergency lighting, hoist servicing and maintenance books were in date. The home has policies and procedures to include, staff training, health and safety and manual handling Record in relation to residents’ money was satisfactory. 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 27 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 X 4 X 5 3 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 2 27 3 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 X 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 28 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. Standard YA24 Regulation 13 Requirement Ensure that generic risk assessment is undertaken to include, the lounge/dining area and any area service users have access to. Replace or repair handling equipment with flaking paint and sharp edges. Ensure that identified individual is consulted before bedrail is installed. Ensure that the complaint procedure contain updated information about the Commission for Social Care Inspection. Ensure that the stain on one service users carpet is removed to provide a comfortable environment for the individual. Timescale for action 30/12/07 2. YA29 13 31/12/07 3. YA7 12 31/12/07 4 YA22 22 31/12/07 5. YA26 23 31/12/07 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 46 Bath Road DS0000003384.V347670.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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