Inspection on 24/04/07 for 63 Lambrook Road

This inspection was carried out on 24th April 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63 Lambrook Road 05/10/06

63 Lambrook Road 15/12/05

63 Lambrook Road 14/07/05

63 Lambrook Road 15/03/05

63 Lambrook Road 08/11/04

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 63 Lambrook Road Fishponds Bristol BS16 2HA Lead Inspector Sandra Jones Key Unannounced Inspection 24 & 25th April 2007 09:30 th 63 Lambrook Road DS0000026540.V337513.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 63 Lambrook Road DS0000026540.V337513.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. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Lambrook Road Address Fishponds Bristol BS16 2HA 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 9655912 0117 9709301 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Lawrence Bartlett Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 4 persons aged 40 years and over. May accommodate up to 4 persons with a learning disability who also have a physical disability. Date of last inspection Brief Description of the Service: 63 Lambrook Road is a domestic style house in a suburban setting providing accommodation for four people with mild learning difficulties and varying levels of physical disability, operated by Milestones and Aspects Trust. The house was built in the 1960s and has had some adaptations made to the home in order to meet individuals needs. The main Fishponds Road shops are within easy reach by wheelchair or walking. The home has four single rooms and a lounge/dining room. There is both a front and back garden with a patio. 63 Lambrook Road DS0000026540.V337513.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 three days in April 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. Two completed “Have your say” surveys were received at the Commission from people who use the service and one was completed at the home. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. Three relatives surveys were received from families and friends. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Four 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 either by face- to- face discussions or by surveys. What the service does well: The people living at the home have a spacious and comfortable environment and are supported to lead active lives. People living at the home have some responsibility for the running of the home. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 6 People living at the home stated that the staff treat them well and have the skills to meet their needs. It was reported that they know who to approach with complaints and information is explained to them. “Have your say” surveys from relatives indicate that the staff at the home are friendly and treat the people living at the home as individuals. The staff are a consistent team who have worked at the home for several years and have a good understanding of their roles and responsibilities. What has improved since the last inspection? What they could do better: The manager must ensure that written information is accessible so that the people living at the home can make decisions independently. This would help individuals at the home to be more involved in decisions about their lives and the running of the home. In assisting people to make choices, the staff must listen to the person in the way they communicate. Policies and procedures must be reviewed to ensure that the standards of care are set within current good practice guidelines. Support plans and core assessments must further developed by incorporating the needs raised during reviews and assessments. It is evident that three people have spiritual needs and one person chose the home because their spiritual needs could be met. For this reason the individuals spiritual needs must be added to their support plans. Goals and wishes must form part of the support plan to ensure that all aspects of the individuals personal development is addressed and seek from individuals what is important to the person, the support they require and may assist to set actions for change. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 7 The comments made by people living at the home indicates that the manager must clarify their rights specifically privacy and dignity. In terms of the comments made by relatives the manager must ensure that bank staff are suitable to work with vulnerable adults. People living at the home must be clear about what they can expect from staff. While people living at the home stated that the staff would be approached with complaints and feel able to make complaints. The manager must ensure that complaints are resolved. This will show that comments made are taken seriously and individuals are respected. 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. 63 Lambrook Road DS0000026540.V337513.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 63 Lambrook Road DS0000026540.V337513.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. There is an effective admissions procedure in place which enables new people to make an informed choice about moving there. People moving into the home must be reassured that there are enough resources to meet their assessed needs. EVIDENCE: There was one admission to the home since the last inspection and this person was consulted about their experience of the process. It was understood that after visits to other care homes, Lambrook Road was chosen because the home could meet their spiritual needs. However, visits to a place of worship does not occur weekly. (Please See Individual Needs and Choices for a full description). Visits for tea took place before the trial period, which enabled this individual to make decisions about living at the home. It is evident that Local Authority needs assessment and health care needs assessments were conducted before the admission to the home. A home’s assessment is in progress based on personal needs including eating, drinking, mobility, health 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 10 and social care. It is sectioned into “What I can do,” What I do I need help with.” The member of staff in charge stated that a review with the social worker, and individual took place on Friday about this individual’s long-term arrangement. However, care plans based on information gathered from assessments and the individual was not in place at the time of the visit. For the needs identified to be consistently met by the staff care plans must be developed from information gathered. 63 Lambrook Road DS0000026540.V337513.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 people who use the service can benefit from a consistent service. People at the home must have written information that is accessible so that they can make decisions independently. Risk assessments are in place for activities that involve an element of risk. EVIDENCE: South Glos. currently fund three people’s placement at the home and the care manager reviews their needs annually. The care manager will then convene a review meeting with the individual, members of staff from the home and where appropriate their relative. Bristol City Council funds one person and the staff at the home undertake this person’s annual reviews. It is clear from the minutes of the review meetings that individuals at the home attend their review meetings. The member of staff in charge said that where necessary core assessments are amended following the review meetings. From the 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 12 annual meetings, support plans are also devised which are sectioned into Why, Options and systems for support. The needs identified by the individual during review meetings and social workers care plans are not always incorporated into the home’s support plans or core assessments. Needs identified during review meetings must be incorporated into their support plans, to ensure that the staff have clear direction on how they are to meet all aspects of the persons life. Each month the keyworker and the individual will discuss the progress made which include personal care, food and drink, mobility and health along with life skills, social needs, life choices and specific services needed. Individuals at the home were aware that of their support plans. The individuals living at the home and staff confirmed that a keyworker system is in operation. Individuals consulted described the role of their keyworker, it was stated that their keyworkers arrange trips, assist with purchasing personal items and 1:1. It was understood from the member of staff in charge that advocates no longer visit the home. The manager said on the second day of the visit that one person has an advocate and visits take place weekly. The member of staff stated that individuals at the home are able to communicate verbally and one person can read to a basic level. In terms of accessibility of information, it was understood that members of staff would sit and explain information to the person. For staff to empower individuals at the home, information must be more accessible. Three “Have your Say” surveys from people living at the home were received. Individuals stated that they make decisions about what they do each day. It was further stated by one person that on Saturdays they are not able to make decisions about what to do during the day. The member of staff explained that generally the staffing rotas are devised so that there are higher staffing levels in the afternoons and weekends. Diaries are in place and members of staff record the daily activities undertaken by the person. Records list hygiene tasks undertaken and daily activities, it was noted from the examination of the records that staff do not sign entries made. The manager compiles risk assessments for any activity that may involve an element of risk. Risk assessments are mainly based on tasks, getting in/out of the car, mobility and medication. It is evident from the records that risk assessments are not currently reviewed along side care plans. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 13 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are good support systems in place for people at the home to lead active and interesting lifestyles. Members of staff support people to access community facilities. People living at the home must be clear about their rights. EVIDENCE: The individuals at the home participate in voluntary employment and attend day care centres. Three people are voluntarily employed by the Disabled Christian Fellowship (DCF) and attend three days per week. The other person attends an activity resource centre four times per week. It was understood by an individual at the home that household chores, visits to shops and restaurants take place on their days at the home. During the visit, the person at the home during the day and keyworker were observed having 1:1 time. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 15 This individual stated that lunch in a restaurant followed by shopping was undertaken with their keyworker. It is evident that individuals goals and wishes are discussed during review meetings. Keyworkers also make suggestions of activities that the person may wish to experience during the meetings. Wishes and goals identified through review meetings are not always incorporated into support plans. The staff must make sure that the individual’s goals and aspirations are recorded in their support plans. This would ensure that each person is offered opportunities to plan and have the support and services they receive designed around what is important to them now and in the future. Three people at the home have spiritual needs and while documentation for one person states that going to church is important, support plans to meet the needs are not in place. One person giving feedback stated that the home was chosen because their spiritual needs could be met at the home. Additionally it was reported that they are able to attend church services every three weeks. This individual explained that weekly visits to church would be desirable. It was understood by staff at the home that because of transport, individuals are no longer able to visit their place of worship every week. The home’s transport is no longer available and disabled taxis can only take two wheelchairs, putting additional strain on finances. The manager stated one person visits their place of worship each week and therefore they are meeting their spiritual needs as other individuals wish is to go less often. The three relatives stated through surveys that because a home’s vehicle is not available the individuals are not able to go out as a group. The Statement of Purpose confirms that visitors are welcome to the home and stipulates that the aim is to support individuals to maintain contact with family and friends. The staff on duty stated that the individuals living at the home have visitors. There is a visitor’s book for visitors to specify the date, the time and the purpose of their visit. Three completed “Have your Say” surveys were received from relatives about the standards of care observed at the home. Comments were made that bank staff do not respect the privacy of people living at the home. One representative stated “Respect people’s privacy when they are in their rooms by knocking and asking them to come in”. Staff Code of Conduct, Visiting, Privacy and Dignity policies set the standards for respecting the rights of the individuals at the home. These policies and procedures must be reviewed to ensure they meet current good practice guidelines. It was understood from one individual at the home that bedrooms are single and lockable. It was further stated that keys to the bedroom, lockable space and front door keys were provided. It is evident from discussion with another person that the expectations about closing bedrooms doors at night needs to be clarified. This individual stated that bedroom doors must be left open during the night in case of fire and for sleeping staff to 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 16 undertake fire checks. A member of staff on duty was consulted and stated that one male individual “is happy to leave their bedroom door open at night.” The manager stated that since taking the post at the home, it was their understanding that a male individual will leave the bedroom door open and light on. The manager must ensure that the people living at the home are clear about their rights, specifically their right to privacy. The people living at the home can expect that members of staff respect their personal space. The Service User Guide states that individual living at the home are encouraged and supported to be independent. Individuals are expected to take responsibilities for cleaning and tidying their bedrooms, undertaking their laundry and meal preparation. During the visit the member of staff on duty was observed supporting one person to prepare their evening meal. Two individuals were at the home and were able to describe the household chores that they undertake. Individuals stated that polishing, laying tables, stripping the bed and meal preparation were some of the household chores undertaken. Individuals at the home stated that mail is handed unopened and were necessary staff will read the letter to the person. A record of the food provided is maintained and the range of fresh, frozen and tinned foods supported the record in place. One person is supported to plan weekly menu with their keyworker. A record of fridge, freezer temperature and cooked meat is maintained 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People that live at the home can expect sensitive and prompt support with their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Support plans in place are not clear about the level of care to be provided by the staff to people that have personal care needs. Two people giving feedback stated that members of staff support them with their personal care. The members of staff on duty stated that the people living at the home have mobility needs and require some assistance with moving and handling. Two people are wheelchair users and it was understood that aids for transferring and getting in/out of bed are not needed. It was further stated that the bathroom was recently adapted into a wet room to increase the levels of independence for the people at the home. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 18 Health Care Action plans are in place for people living at the home. Action plans list the health care needs, action to be taken, frequency and date of review. Significant areas of need are highlighted in red and where the need is minimal, green is used. For one person with pressure sores the action plan instructs staff to conduct checks for signs of deterioration. A description of the signs of deterioration must be included within the record. Documentation based on the management of pressure areas has not been reviewed since 24/06/06. The manager stated that he is satisfied with the reviewing plans. Documentation in place from health care professional evidence that where appropriate referrals are made for specialist support. The people at the home access NHS facilities and, regular visits are arranged to the dentist, optician and chiropodist. Individuals consulted about their health care stated that the staff accompany them on health care visits. Surveys from representatives indicate that their relative’s health care needs are always met. Two people currently self-medicates and the staff administer medications to another person. Medication profiles are in place and list the name of the medication, its purpose, dosage and directions, with additional information about the use of the medication and how it works. A monitored dosage system is in place for medications administered by the staff. Records of administrations indicate that staff sign the records immediately after administering medications. Homely remedies are not administered from a stock supply when required. 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that live at the home feel confident to approach the staff with concerns and can expect to be protected from abuse. To values the views of the people living at the home, complaints raised must be acted upon. EVIDENCE: Three completed “Have your Say” surveys were received from individuals at the home, which state that they would speak to staff if they are not happy. Surveys received from three relatives indicated that the care home always responds appropriately to concerns raised. During the visit, the comments of two people were clear about approaching staff with complaints. Regarding making complaints one person stated through the survey that they always know how to make a complaint. One person indicated sometimes and the other did not know how to make a complaint. The home’s Complaints procedure is written in a simple format with pictures to ensure that the people for whom its intended can understand it. It was stated by the individuals at the home that they are not provided with copies of the complaints procedure. Members of staff explained that the procedure is explained to individuals and regularly discussed. Two complaints were received at the home in February 2007 from one person living at the home. It was understood that the complaint about the garden is being managed by the Trust through the estates department. The other 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 20 complaint is about dining room furniture and although it states that it has been actioned, it remains outstanding. Aspects and Milestones Protection of Vulnerable Adults and Suspicions of Abuse are in place. The Local Authority “No Secrets” guidance is also available at the home. The manager confirmed that individuals that may at time exhibit violent and aggressive behaviours are not accommodated at the home. Regarding staff disciplinary, the manager stated that there are none in progress. 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is maintained to an adequate level and for individuals to benefit from living in a comfortable environment, improvements must continue. EVIDENCE: The home has the appearance of a domestic dwelling, which blends well with its local environment. The property is a detached bungalow arranged into single bedrooms with a large lounge/dining room, kitchen and laundry room. It is near Fishponds Road and within walking distance of shops, pubs, amenities and bus routes. There is level access into the home. Wheelchair users are able to move around independently because of the wide corridors, doorways, space for turning and accessing personal belongings. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 22 It is evident from past inspections that the process for making improvements has begun. The bathroom was converted into a walk in shower and the kitchen was refurbished which meets the changing needs of the people accommodated at the home. While it is acknowledged that the individuals at the home require equipment and aids to move around the home independently, the corridors appear functional and less homely. Improvements must continue to fully provide a homely environment. The laundry room is adjacent to the kitchen, with painted walls and vinyl flooring for easy cleaning. There is a domestic washing machine, tumble dryer and wash hand basin. 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Individuals at the home are supported by competent, qualified and skilled staff team who are well supervised. The manager must ensure that bank staff are suitable to work at the home. EVIDENCE: Personnel files of the staff working at the home were examined during the site visit. Four support workers are currently employed and have been working at the home before the introduction of NMS. Completed application forms, written references, certificates and associated documentation are kept in personnel files. The Trust currently notifies the manager about the outcome of Criminal Records Bureau (CRB) disclosure checks. The written notification lists the serial number, the date and the level of clearance. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 24 It was understood from the manager that there is a vacancy and a person already employed by the Trust will cover the hours. This individual will be undertaking the home’s induction programme. Three completed surveys were received from relatives and their comments indicated that the staff, employed has the skills to meet the changing needs of the people at the home. However, two relatives were critical about the skills of the bank staff. One person stated “ Bank staff should have more training in communication with individuals, which make them more secure”; another stated, “ We think you should sometimes consider the quality of the bank staff as they may sometimes not be suitable.” Permission was sought from these individuals for the manager to investigate the allegations made. Members of staff were consulted about the training available at the home. It was understood that the Trust training bulletin is available and staff choose courses from the bulletin. It was further stated by the staff that the manager encourages staff to undertake training. Records examined indicate that since the last inspection members of staff have attended Dementia Awareness and Fire training. Also, the staff at the home have completed NVQ level 3. The manager stated that dementia care course was undertaken to develop staff’s insight. It was further stated that an annual programme of training is not yet in place, although other training specific to the home is being assessed. 63 Lambrook Road DS0000026540.V337513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living at the home can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The people that live at the home and members of staff made favourable comments about the manager’s style of management. One member of staff stated that the manager has introduced solid structures for staff to work from, which establish a sense of security for the people living at the home. The staff stated that individual supervision, staff meetings and handovers when shift changes occur are the processes that ensure consistency of care. One individual living at the home said, “Lawrence is wonderful and the staff are even better”. 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 26 Three completed surveys were received from relatives and indicated that the people living at the home are encouraged to be independent and are seen as individual by the staff The manager was consulted about the home’s Quality Assurance system and it was understood that the Trust operates a peer support audit. This entails managers undertaking reviews of each other’s care homes, with the purpose of developing systems and processes that ensure standards are met. It was further stated that through the audit system the home would meet the wishes and aspirations of individuals at the home. Additionally, a review has taken place for the home. However, the written report of the audit is not yet available. A business plan was devised in January 2007 with the manager, staff and external manager. The home maintains an accident book and since the last inspection, two accidents were recorded. One relates to a fall and the other to incidents of violence and aggressive behaviour and both incidents were managed appropriately. Health and Safety checks are conducted to maintain a safe environment for the people at the home. The home complies with associated legislation by the regular checks of gas and portable equipment. The records that relate to fire safety checks and practices were examined. The manager completed fire risk assessments in July 2006. It is evident from the documentation in place that the Fire procedure must be clear about the actions that staff must take in the event of a fire. 63 Lambrook Road DS0000026540.V337513.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 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 28 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. Standard YA6 Regulation 15 (1) Requirement Needs identified through reviews and assessments must incorporated into support plans to ensure individuals needs are consistently met at the home The manager must ensure that the individuals spiritual needs are met. Individuals wishes, goals and aspirations must be added to their person centred plans The manager must ensure that the privacy and dignity of the individual is respected. Complaints must be fully investigated and actioned The manager must consult with the Fire Authority to ensure the safety of the people at the home. The manager must ensure that bank staff are suitable to work with vulnerable adults Timescale for action 31/08/07 2. 3. 4. 5. 6. 7. YA6 12(4) (b) 12 (3) 12 (a) 22 23 (5) 31/08/07 31/08/07 30/06/07 30/06/07 30/06/07 30/06/07 YA12 YA15 YA22 YA42 YA34 18 (a) 63 Lambrook Road DS0000026540.V337513.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 63 Lambrook Road DS0000026540.V337513.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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