Inspection on 09/11/07 for 6 Northumberland 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

6 Northumberland Road 19/11/08

6 Northumberland Road 22/11/06

6 Northumberland Road 01/12/05

6 Northumberland Road 11/07/05

6 Northumberland Road 04/03/05

6 Northumberland Road 25/05/04

Similar services:

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Trevaylor Manor

Stallcombe House

Stroud Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 6 Northumberland Road Redland Bristol BS6 7AU Lead Inspector Sandra Jones Key Unannounced Inspection 9th November 2007 09:30 6 Northumberland Road DS0000026564.V353170.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 6 Northumberland Road DS0000026564.V353170.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. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 6 Northumberland Road Address Redland Bristol BS6 7AU 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 9423628 0117 9709301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Antony Swanborough Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 18 years and over requiring personal care. 22nd November 2006 Date of last inspection Brief Description of the Service: 6 Northumberland Road is an older property in a residential area. There are 5 single bedrooms and a communal lounge and dining room. There is a back garden with a small drive at the front of the house. There is no disabled access or lift facilities. The fees for staying at the Home range from £715.00 per week. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced over one day in November 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection and notified incidences in the home, (Regulation 37’s). An Annual Quality Assurance Assessment (AQAA) was sent with surveys for people living at the home, their relatives, social and health care professional involved at the home. The completed AQAA and surveys from relatives and health care professional was returned to the Commission and this information was used to plan the inspection visit. However, the manager failed to return surveys from people at the home. Five people live at the home and five people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered through face- to- face discussions. What the service does well: The individual’s comments about the standards of care show that people have the freedom to leave the home without support. People at the home were confident that members of staff would take their concerns seriously and act upon them. People at the home also said that they were treated well by the staff and they had the skills to meet their changing needs. One relative stated through the survey that “Overall we are very satisfied with the way the home is run which now gives us all peace of mind.” 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 6 A health care professional stated through the “Have your say” survey that “the team at Northumberland Rd. provide a calm and relaxed environment for the residents and the overall fell of the home is one of respect for individuals that it is their home rather than the staff work place.” What has improved since the last inspection? What they could do better: Requirements arising from this inspection are based on reviewing information, developing systems and providing a homely and safe environment for the people living at the home. The Statements of Purpose and Service User Guide must be reviewed to ensure that the people wishing to live at the home can make decisions about moving to the home. In terms of the Statement of Purpose, information about the criteria for admission and the range of needs that can or cannot be met must be included. House rules and expectation must be specified within the Service User Guide. The introduction of a person centred approach to meeting needs will ensure that individuals at the home benefit from a consistent and individualised care. An assessment of the care action plans must be undertaken to establish the progress being made by the person. Risk assessments must be completed for individuals that self medicate to show that appropriate action is taken to reduce the level of risk. Regarding the current practice of locking the kitchen at night risk assessments that supports locking the door reduces the level of risk must be completed. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 7 For the people at the home to live in a homely and safe environment, the furniture in the smoking lounge must be repaired/replaced and attention must be given to the peeling paint and ceiling in the kitchen. The home must follow the fire risk assessment action plan to reduce the risk of fire at the home. 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. 6 Northumberland Road DS0000026564.V353170.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 6 Northumberland Road DS0000026564.V353170.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Once Information is up to date and comprehensive individuals wishing to live at the home can make decisions about moving into the home. EVIDENCE: The member of staff on duty said that the individuals at the home have lived together at the home for five years. It was further said that while there is a very independent person who will be moving in the future there are no expected discharges. The prepared Statement of Purpose and Service User Guide briefly describes the range of needs that can be met at the home, the facilities available at the home and the skills and qualifications of the staff. Policies and procedures that enable individuals to make decisions about living at the home are included. The Statement of Purpose and the Service User Guide must be reviewed to ensure correct information is included. Further information regarding the range of needs that can and cannot be met and the criteria for admission to the home must be added. For example, the home is not able to provide accommodation to people that have physical impairments. The member of staff on duty said that the individuals at the home would be able to read and understand the documents. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 10 One “ Have your say” survey was received from an relative which states that it was usual for the home to provide enough information about making decisions to live at the home. 6 Northumberland Road DS0000026564.V353170.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The care planning system must be more effective so that the people at the home can benefit from individualised and consistent standards of care. People at the home can expect to be involved in all aspect of decisionmaking. EVIDENCE: The case records of the people living at the home contained copies of the contract, assessment of needs, home’s care plans, daily reports and associated documentation. Individuals at the home attend Individual Care Planning Approach (ICPA) review meetings with home staff, health and social care professional and, home care plans follow from the ICPA meetings. Care plans list the area of need, the goals and the actions to be taken, which the person signs to indicate their awareness of the plan of action. While care plans are reviewed regularly the action plans have not changed since 2005 and changes in needs have not been brought forward into the action plans. The manager must assess the 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 12 suitability of the action plans and must use a person centred approach to meeting assessed needs. Where the individuals likes, dislikes and preferred routines is used to develop care plans, a person centred approach to meeting needs will then be developed. This will also ensure that staff have up to date information that will guide the staff to consistently meet the needs of the person. Four people living at the home were consulted about the care planning process and their comments indicate that they attend ICPA review meeting. Members of staff said that they generally attend ICPA meetings and it is the manager who develops the care plans. One relative stated through the “Have your Say” survey that “ I am very pleased with the care my relative receives, I found the staff always friendly and willing to share information regarding their well being.” For individuals that become aggressive and violent, risk assessments are clear about the actions that staff must take to protect others, the people at the home and the property. Three individuals giving feedback about the standards of care were not aware of that they had a keyworker. The manager said that because of the current staffing levels, the keyworker system is not in operation. One person has restriction imposed on community-based activities. Individuals at the home confirmed that they are able to make decisions mainly about meals and clothes. The people at the home have family support but not all advocate on behalf of their relative. Members of staff said that individuals at the home are able to make decisions about all aspects of their daily lives. The manager said that following from Mental Capacity training, a statement regarding the person’s ability to make decisions would be appended onto the care plan. Risk assessments are in place for individuals that leave the home unsupported by staff, using kitchen equipment, using the stairs and personal care. 6 Northumberland Road DS0000026564.V353170.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals are able to pursue their lifestyle and are valued members of the community. EVIDENCE: Four people at the home have community-based activities, one person has part-time employment, one person attends college, another attends a day care centre and the fourth person visits a drop-in centre. The manager said that during Individual Care Planning Approach (ICPA) meetings, individuals are asked about their goals and aspirations. It was further stated that four people went on holiday for the second year and the group leads the trips organised. Individuals giving feedback during the visit confirmed their community based activities and explained that watching television and reading newspapers are some of the activities undertaken during the day. The people at the home stated that they are able to leave the home without staff support and described the local facilities used. The people living at the home use coffee shops, banks, post office and other amenities. Members of 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 14 staff giving feedback said that while the people at home can leave unsupported, if support is requested staff will accompany individuals. The manager said that the neighbours know the people that live at the home. It was further stated that the individuals at the home requested an organised trip to see a firework display and additional staff was rostered for the event. The arrangement for visitors is included within the Statement of Purpose. Where maintaining contact with family is an assessed need, developing relationships forms part of the care planning process. Individuals giving feedback described the contact they have with relatives and their comments indicate that visits can take place in bedrooms for additional privacy. The relative that responded through the “Have your say” surveys said that the home keeps them informed about important issues that affect their relative. The manager said that the Privacy and Dignity policy, Staff handbook, training and induction ensure that the staff respect the people living at the home as individuals. The Privacy and Dignity policy must be reviewed to make clear the rights of the individual. House rules are based on smoking, noise levels, household chores and respecting others privacy. However, the house rules are not currently incorporated into the Service User Guide. The manager said that the tenancy agreements make a reference to not breaking the law and this refers to rules on drug abuse. Individuals were consulted about the way their rights are respected at the home and comments indicate individuals awareness of the rules regarding smoking, respecting privacy and expectation to undertake household chores. Individuals confirmed that their mail is handed to them unopened and staff knock and wait for an invitation to enter bedrooms. During feedback individuals stated that bedroom keys are not provided and the kitchen door is locked at night. The manager acknowledged that individuals bedroom keys must be replaced. Bedrooms keys must be replaced and a risk assessment that supports locking the kitchen door at night reduces the level of risk. During the discussion the manager was not able to produce a risk assessment in respect of locking the kitchen door. A risk assessment was provided to the Commission prior to the publication of this report. Menus are devised and written by the people living at the home, which are varied, and the range of fresh, frozen and tinned foods supports the menu in place. Comments from the individuals at the home confirmed that there was enough to eat, they enjoyed the meals served and that they assisted staff to prepare meals. One person said that the kitchen is locked at night. The manager must complete a risk assessment for locking the kitchen door, which shows that locking the door reflects the level of risk. 6 Northumberland Road DS0000026564.V353170.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals at the home have sensitive and prompt support for their personal and health care needs. EVIDENCE: Care plans are in place for individuals with personal care needs. The manager said that one person has personal and health care needs. People at the home were consulted about health and personal care and feedback indicates that one person has assistance with personal care from the staff. One individual confirmed that staff provide assistance with bathing and when personal care is provided the staff respect their rights. The manager said that the people at the home are fully ambulant and aids and equipment is not needed to maintain their level of independence. The people living at the home have psychiatrists involved in their care and form part of the Individual Care Programme Approach (ICPA). The manager said that where Occupational Therapists (OT) are involved, they fulfil the role of the care coordinator and currently two people have OT involvement. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 16 Individuals at the home have annual health checks and access local NHS facilities, which include dentist and optician. A record of health care appointments is maintained and listed is the date, nature and outcome of the appointment. Two individuals consulted said that they are accompanied on health care visits and two said they visit their GP without staff support. Staff say that to reduce level of anxiety they sometimes escort individuals on GP visits and hospital appointments. Staff also say that to ensure that health care advice is consistently met, outcomes of visits are recorded and passed on when shift changes occur. Individual profiles that describe the purpose of the medication and its side effects are in place. One person currently self medicates. However, a risk assessment that shows that this person’s level of competency was assessed and preventative measures introduced to reduce the level of risk, is not in place. Risk assessments must be developed for individuals that self-administer their medications. One individual may refuse to take their medication and a risk assessment that guides the staff on the actions that must be taken is in place. There is a protocol in place for the individual that is prescribed “When Required” medication, which instructs staff to contact the Trust before medication is administered. Medications are administered from a monitored dosage system and the records of administration were checked against the medications held within the systems. It was noted that for one person the instructions on the package was not the same as the medication administration sheet. The manager acknowledged that the pharmacist must be contacted to ensure the correct direction is put onto the packaging. Homely remedies are administered from a stock supply when required by the person and the records examined crossreferenced with the balances held. A record of medications no longer required at the home is maintained and signed by the pharmacist to indicate receipt of the medication for disposal. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The “Have your say” response from a relative indicates that they are aware of the complaints procedure and the home responds appropriately to their complaints. Four people were consulted about the way complaints are managed at the home. Individuals at the home named the person that they would approach and were confident that the staff at the home took their concerns seriously and acted upon them. Members of staff said that they discuss the complaints procedure during house meetings to make individuals aware that their feedback is welcome. It was also stated that by having an approachable attitude and by being available, individuals feel able to express their views. The manager said that the complaints procedure is regularly discussed with the people at the home and individuals are provided with copies of the Service User Guide, which contains the Complaints procedure. The manager said that two individuals have the potential to exhibit aggressive and violent behaviour. Where individuals become aggressive or violent to others, strategies instruct staff to contact the police or senior staff. When the strategies are next reviewed, staff must also be guided, where appropriate, to report the incident to Safeguarding Adults. The manager said the Whistleblowing, Protection of Vulnerable Adults, Bullying and Harassment policies ensure that there is a set approach for safeguarding 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 18 individuals from abuse. Members of staff consulted during the inspection confirmed that they attended Safeguarding Adults training. Comments made by the staff indicated that they are aware of the factors of abuse and the actions that must be taken for alleged abuse. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home must be better maintained so that the individuals can benefit from living in a comfortable and clean environment. EVIDENCE: 6 Northumberland Road is an older property that has the appearance of a domestic dwelling, which blends well with the local environment and, is within walking distance of local shops and major bus routes. Arranged over three floors with bedrooms on all floors and shared space on the ground floor, there is no disabled access or lift facilities. Accommodation is in single occupancy with toilet and bathroom per bedroom floor. A tour of the premises took place with the manager and four bedrooms were viewed during the tour. Bedrooms contained a combination of the home’s furniture and personal belongings, which support the individuals chosen lifestyle. The manager said that one bedroom is to be redecorated. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 20 The main lounge is a designated smoking area and it is well ventilated with sufficient seating for the three people that smoke. However, the sofa and chairs in the rooms are clearly in need of replacing/repair. The dining room also has seating a two-seater sofa and one chair mainly for non-smokers. The kitchen has peeling paint and the ceiling is in need of attention. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A motivated, competent and effective staff team who are appropriately supervised support individuals at the home EVIDENCE: Six people are currently employed at the home and the manager said that two people living at the home are involved in the recruitment process. These individuals are involved in setting the advertisements for new staff, setting the criteria and are part of the interviewing panel. The “Have your say” survey from a relative states that the staff usually have the skills to meet the needs of the people at the home. Comments made include “The people that we have contact with seem very skilful in their job and have my relatives’ best interest at heart.” Two members of staff said that training is accessible, it was further stated that staff must complete statutory training, in-house and vocational qualifications. The manager explained the statutory training that staff must attend and since the last inspection staff have attended assertiveness, group working, stress and IT courses. Autism training will be arranged for all staff in January to 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 22 ensure the staff can meet the changing needs of the people at the home. The psychologist and Community Psychiatrist Nurse (CPN) involved in the care of the people living at the home provided mental Health training to the staff. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals can be re-assured that the standards of care are subject to on going monitoring. For individuals to live in a safe environment the home must follow fire risk assessments in place. EVIDENCE: The manager said that the style of management used is dictated by the home and the abilities of the staff. There is a democratic way of doing things although an autocratic approach may be used at times. Individuals at the home are encouraged and enabled to build good therapeutic routines to empower the person. The manger said that staff meetings and individual supervision are the systems used to maintain consistency and members of staff confirmed the statements made by the manager. Members of staff and people living at the home were consulted about the style of management used. Members of staff said that there is a commitment to people at the home, 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 24 which is supportive to everyone. The four people giving feedback said that they are treated well by the staff and manager and one person said, “There are the odd flare ups like the misunderstanding that happened last week.” The manager completed the Annual Quality Assurance Assessment for the home. Surveys for individuals living at the home, health care professional and relatives were sent to the home for completion. However, surveys for individuals were not distributed. The manager said that the Trust has introduced a Quality Assurance system and care home managers will audit the each other home. It was further stated that the audit report for the home was with the external manager. The duty rota in place shows that there are two staff on duty throughout the day with one person sleeping-in at night. There are facilities for safekeeping of cash and valuables on behalf of the home. One person has cash in safekeeping and the records of each transaction is detailed and signed by the person. Fees at the home are £715.00 per week. The manager also complies with associated Health & Safety legislation by the annual checks of the gas boiler and portable equipment. Fire Risk assessments are in place. However, the home is in breech of their own risk assessments because staff have not attended six monthly fire drills. The manager must ensure that fire risk assessments are followed to maintain a safe environment for the people at the home. 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 x x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 6 Requirement The Statement of Purpose must be reviewed and specific information about the criteria for admission and the range of needs must be included. The manager must assess the suitability of the care action plans. A person centred approach to meeting needs must be used in the care planning process. House rules and expectations must be included within the home Service User Guide. Risk assessments must be developed for individuals that self administer their medication must a) The furniture in the smoking must be repaired/replaced b) the peeling paint in the kitchen is in need of attention. c) The ceiling in the kitchen is also in need of attention. The home must comply with the fire risk assessments in place. All staff must undertake fire drills at six monthly intervals. Timescale for action 30/03/08 2 3 4 5 YA6 YA6 YA1 YA20 15(1) 12 (3) 5 13 (2) 30/03/08 30/03/08 30/03/08 30/12/07 6 YA24 23 (2) 30/04/08 7 YA42 23 (4a) 30/12/07 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 27 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 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 28 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 6 Northumberland Road DS0000026564.V353170.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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