Inspection on 05/10/06 for 63 Lambrook Road

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63 Lambrook Road 24/04/07

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 Sarah Webb Key Unannounced Inspection 4 & 5th October 2006 11.30 th 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 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.V293584.R01.S.doc Version 5.1 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.V293584.R01.S.doc Version 5.1 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.V293584.R01.S.doc Version 5.1 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. 15th December 2005 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.V293584.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as an unannounced inspection and took place over a period of 2 days and a total of 10 hours. The inspection methods used included record checks, case tracking, discussion with the manager and staff and discussion with 3 residents. The home has improved in complying with requirements and recommendations. Two immediate requirements and seven requirements have been met, leaving one that is unmet. This is in relation to keeping a record of staff training. Two recommendations have been met. The manager Mr Bartlett is now based at Lambrook Road on a full time basis. It was evident that he has made improvements to the running of the home with more efficient systems in place in order to monitor the care and management of the home. The home has also altered the environment to meet the changing needs of residents and there are other also planned changes in the near future that will benefit residents’ lifestyles. What the service does well: What has improved since the last inspection? All staff have received fire training at regular intervals, with a record kept. (This was an immediate requirement) The home keeps a record of all medication received from the pharmacy and any medication disposed of in order to ensure the health, safety and welfare of residents. (This was an immediate requirement) 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 6 The home has both updated and carried out individual and generic risk assessments including those in relation to the moving and handling of residents. The home has risk assessed financial procedures relating to the management of residents monies, including the current practice of withdrawing monies on their behalf and has reviewed the arrangements in place for the monitoring and control of financial procedures. Records held in the interests of the residents have been updated, signed and dated. The home has reviewed three residents care plans in order that their assessed needs are met. The home has refurbished the bathroom meeting the physical needs of an individual as assessed by specialist services. The home has maintained fire equipment on a regular basis in order to ensure the safety of individuals. Three staff have updated food hygiene training in order to ensure the welfare of individuals. 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. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, & 5 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Existing and prospective residents are provided with relevant information in order to make informed choices about the home. Prospective residents can be assured that their needs will be assessed prior to moving in. Residents have a written contract stating the terms and conditions of the home. EVIDENCE: The manager has revised the statement of purpose that includes comprehensive information as set out in Schedule 1 providing relevant details of the operation of the home. The service user guide is in accessible format and informs residents of their stay. There have been no new residents admitted to the home since the last inspection. All bar one resident have lived at the home for a considerable time. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 9 Residents care files contained assessments and care planning undertaken by funding authorities. The manager completes 6 monthly assessments as required by Bristol social services. A resident has recently been referred to a specialist service for assessment of a specific need. Residents’ contracts set out services provided, including extra charges, insurance, house rules, and the ending of placement. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9. Quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The home provides a satisfactory care planning system for residents that provides staff with the information they need in order to meet individual needs. The arrangements in place to minimise risks so that the safety and welfare of individuals are promoted have improved. EVIDENCE: All four residents care files were examined; comprehensive information was available including individuals’ personal details, preferences, personal support needs, and life skills. A requirement has been met for care plans to be up dated and reviewed. It was evident that this is an area that has improved with the manager putting systems in place to ensure that residents’ care needs are monitored on a regular basis. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 11 Records identified that staff carry out monthly support reviews with an annual service review held annually. All residents had been reviewed through this process. A resident spoken with was aware that they had a care plan; they said their keyworker was involved in having meetings with them to discuss any changes. Since the last inspection, residents have benefited from an advocate who has been responsible for supporting house meetings in order to gain their views. This is good practice. A requirement has been met to update and implement individual and generic risk assessments. These covered areas such as mobility and risk of falls, showering, and handling money. Two comment cards received from families indicated that they are kept informed of any important changes affecting their relative and are consulted about their care if appropriate. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to participate in the local community and are offered meaningful activities. Staff support residents with the maintenance of family relationships and contact with friends. The home needs to improve in the recording of meals offered to residents. EVIDENCE: All residents are supported in accessing meaningful activities. Three residents attend a day service run by the Disabled Christian Fellowship for between 3 and 4 days per week. It was evident from discussion with one individual that they enjoyed it very much. A fourth resident attends another relevant day service, a luncheon club, and a community centre. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 13 The manager said that all the residents are known in the immediate community with individuals having contact with their neighbours. Staff support individuals within the community with shopping trips and midday meals at local pubs, café and restaurants. On the day of this visit, a resident went clothes shopping with staff and had a midday meal out in a local restaurant. Discussion with residents and staff identified that holidays took place during the year that were enjoyed by all. Residents spoken to related the contact they had with their relatives and friends, and how staff support and maintain the friendships they have. Comment cards from relatives/families identified that they are welcomed to the home at any time and can visit their relative in private. A resident spoken indicated how staff helped them with household tasks such as cleaning their room and doing their laundry. With the changes planned for the kitchen in terms of a more suitable area for residents to access, the manager said he is also planning to offer residents more opportunities to develop and maintain their independent living skills. He also explained the changes that he plans to introduce regarding expanding choice of meals and improving service users menus in offering more healthy eating options. Observation of the menus evidenced that there is a need for more choices. However staff indicated that residents were clear as to what they wanted to eat and are often resistant to new ideas. A requirement is made for a record to be kept of food offered to residents in order for this to be monitored. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from individual personal support suited to their preferences within an appropriate and suitable environment. The home has improved in the arrangements of safe moving and handling practices. The physical and emotional health needs of residents are well met with evidence of multi disciplinary working taking place. There were safe systems in place for the administration of medication, however consent needs to be obtained from residents and a self medication risk assessment needs to be carried out. EVIDENCE: Residents have varying levels of assistance and are supported with their personal hygiene and bathing. All residents also require the aid of a wheelchair both internally and externally. A requirement has been met for risk assessments to be completed in relation to the moving and handling of residents. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 15 A requirement has been meet for the home to set out an action plan as to how the home will meet the physical needs of a resident as assessed by specialist services. The existing bathroom environment has now been altered in order to meet their changing needs and those of the other residents. This is recorded in Standard 24. During this visit it was evident that the home was still waiting for a shower chair; however since this visit a complaint was made by a specialist service involved in the residents care in relation to the delay. The outcome is that the home has now received the equipment that is proving successful. Observation of residents’ healthcare records identified that individuals’ health and welfare is monitored on a daily basis. Documentation evidenced that residents are supported with appointments to doctor, specialist services, dentist and optician. Referrals are made through the local Community Learning Disability Team for support by specialist services such as occupational therapist, physiotherapist and speech therapist. Health Action plans identified individuals healthcare needs. There was clear documentation in relation to the prevention and monitoring of pressure scores. This is good practice. The home has both the organisation and a local medication policy in place. It is evident that procedures for the safe administration of medication have improved. All residents have a medication profile with photographic identity. Medication continues to be provided by a local pharmacy in the form of medidose boxes on a weekly basis. An immediate requirement has been met to keep a record of both the receipt and disposal of medication. Documentation evidenced that the receipt, administration and disposal records were up to date and in order. There is one resident who self medicates and has a weekly supply of medication. The staff carry out monitoring checks periodically. However there was no evidence that a risk assessment had been completed in relation to his self medication. Therefore a requirement is made for this to be implemented. A requirement is also made to obtain residents consent to medication being administered. The home has arrangements in place for medication to be administered outside of the home during residents’ day activities. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 7 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents views are listened to and acted on; however all actions and outcomes in relation to any complaint need to be recorded. The home has improved in the arrangements in place regarding financial monitoring and controls measures in place in order to protect individuals. The home follows appropriate procedures in order to protect residents from abuse. EVIDENCE: The organisation has a comprehensive complaints policy and the home’s policy is on display. The manager said that the monthly service reviews and the house meetings offer the opportunity for service users to communicate any concerns and complaints formally. Any difficulties that do arise are resolved very quickly through the key worker system and the close relationships that exist in the home with a long serving staff team. This was evidenced through discussion with a resident. A resident has made a complaint that is in the process of being dealt with by the organisation. Although this person has had a visit from a senior manager in response to their complaint, there was no record in the complaints log of action taken or any outcome. A requirement is made for the home to keep a record of any action taken and the outcome of any complaint. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 17 Comment cards received from relatives stated that they are aware of the homes complaints procedure; neither relatives’ have had to make a complaint. The organisation has policies and procedures regarding the protection of vulnerable adults and whistle blowing. Local Authority policies on the protection of vulnerable adults are available in the home. All staff have completed protection of vulnerable adults training; however there was one staff member who had completed this training four years ago. It is recommended that this member of staff is updated in this area. The manager said he is due to also attend a course in updating his knowledge shortly. A resident is presenting verbal challenges to both staff and other residents living at the home identifying that there are compatibility issues. It was evident through discussion with staff and residents that this ongoing situation has been hard for everyone to manage. Residents and staff indicated that this person’s behaviour has impacted on the home residents staying in their rooms. A resident has spoken to the social services duty team expressing their concern and a complaint has been made to the organisation. The manager has followed appropriate action in raising this issue with relevant authorities regarding the procedure for safeguarding the residents in the home. Reactive strategies have been discussed with staff. They were clear what action to take in order to minimise challenges presented and were monitoring incidents. The home has satisfactory arrangement for residents to access their finances. Two requirements have been met for the manager to review procedures for the monitoring and control of financial procedures and to risk assess financial procedures relating to the management of service users monies, including the current practice of withdrawing monies on their behalf. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location of the home offers easy access to the local community meeting lifestyle needs of individuals. The home has begun the process of making improvements to the home in order to provide a safe and suitable and environment for the residents including a bathing environment that now meets the changing needs of individuals. EVIDENCE: The home is small and domestic in style. The residents have access to local amenities, with the main Fishponds Rd shops being in easy reach by wheelchair or walking. Since the last inspection the environment has improved in that the bathroom has been refurbished with a walk in shower that now meets with the changing needs of the residents. Those residents spoken to were happy with the change. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 19 Staff also said it was safer to support individuals with their personal care needs. The manager explained how the kitchen is also to be refurbished in the near future in order that residents will benefit from an accessible environment. It is evident that the organisation has considered the overall needs of the residents in improving aspects of their lifestyle. The home was clean and free from malodours. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are a consistent and competent team, and have a good understanding of their role and the residents individuals needs. The organisation has robust arrangements for the recruitment of staff. Staff have attended relevant training in order to meet the needs of residents. EVIDENCE: Discussion was had with three members of staff who related that the staff are a consistent and long standing team with most of the staff having worked at the home for several years. Those staff spoken to had a good understanding of what is expected of them and in how they should be supporting residents There are currently no staff vacancies. Staff had previously been used to sharing the manager with another home he was responsible for, but now that Mr Bartlett is based at Lambrook Road on a fulltime basis, staff receive the benefit of a consistent manager. Examination of the rota evidenced that two staff are on duty at any one time. One member of staff is on sleep in duty at night. Concerns were raised through comment cards received from relatives relating to this night time cover and in 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 21 supporting residents in an emergency. This was discussed with the manager who indicated that the organisation has arrangements in place for staff to be supported in an emergency. Four staff have a National Vocational Qualification level 3. This meets with 50 of the homes staff obtaining such a qualification. Staffing files observed contained appropriate documentation such as 2 references, proof of staff identity, a health assessment and application. The personnel department keeps copies of police checks. Although a letter is sent to the manager by the organisation informing him of all staff police checks there is no reference to the outcome of these checks. The manager said he was not aware of a disclosure being made and has not been involved in any discussions relating to this. Examination of records and discussion with staff evidenced that team meetings have taken place regularly. Staff indicated that they receive regular supervision and have good support from the manager. A requirement is unmet made for staffing records to be updated. A recommendation has been met for staff to be trained in food hygiene. Other training attended covered areas such as money handling, and epilepsy. A member of staff was due to attend a training course in relation to the needs of the residents. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has improved in order to support staff within their role and ensure that residents benefit from a well run home. The home needs to ensure staff attend regular fire drills in order to ensure the safety of residents. The organisation has systems in place to gain the views of residents. EVIDENCE: Mr Bartlett has been managing Lambrook Road since June 2006 on a full time basis. He has 17 years experience of relevant experience; he has completed the Registered Managers Award and holds an adult teachers certificate. He also undertakes periodic training in order to update his knowledge. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 23 As previously identified in the Summary of this report it is evident that Mr Bartlett has made improvements to the systems in place to ensure the effective daily running of the home. Documentation and records was easier to find during this visit including monthly health and safety checks, electrical testing, Gas Safety certificate safety and portable appliance testing; these were at hand and up to date. Risk overviews were documented in relation to individuals being left alone, using the washing machine and travelling alone in taxis; they also had been reviewed and were all up to date. Generic team risk assessments covered areas such as food preparation, lone working, and wheelchair checks. An immediate requirement has been met for all staff to receive fire training at regular intervals and that a record is kept. Training records indicated that staff have attended first aid, manual handling and risk assessment training. However records also identified that not all staff have been included in fire drills on a regular basis. A requirement is made to ensure fire drills take place on a regular basis and to include all members of the staff team. Feedback from residents is sought through both monthly and annual reviews and from the advocacy support in place. Mr Bartlett said the organisation is in the process of setting up other managers from other homes to visit in order to obtain the views of residents. The home has a Business plan; this is relative to the needs of the residents living at the home. Comment cards received from relatives identified that they are satisfied with the overall care provided. 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 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 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. Standard YA41 YA17 YA20 YA20 YA22 YA42 Regulation Sch 4(6) Sched 4.13 13(4) 13(2) 22 23(4) Requirement Update staffing records (Carried through from last inspection) Keep a consistent record of food offered to the residents. Risk assess a resident who self medicates. Obtain residents consent to medication being administered. Keep a record of action taken and outcome of any complaint. Carry out regular fire drills for all staff. Timescale for action 31/01/07 06/10/06 06/10/06 30/11/06 06/10/06 06/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations Update a member of staff’s knowledge in the protection of vulnerable adults 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 63 Lambrook Road DS0000026540.V293584.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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