Inspection on 06/07/06 for 76-78 Hampstead Road

This inspection was carried out on 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

76-78 Hampstead Road 26/11/08

76-78 Hampstead Road 04/06/08

76-78 Hampstead Road 05/06/07

76-78 Hampstead Road 15/11/05

76-78 Hampstead Road 13/07/05

76-78 Hampstead Road 13/01/05

76-78 Hampstead Road 18/06/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 76-78 Hampstead Road Brislington Bristol BS4 3HN Lead Inspector Sandra Jones Key Unannounced Inspection 4th & 6th July 2006 09:30 76-78 Hampstead Road DS0000026628.V303263.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 76-78 Hampstead Road DS0000026628.V303263.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. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 76-78 Hampstead Road Address Brislington Bristol BS4 3HN 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 9728513 0117 9699000 www.brandontrust.org The Brandon Trust To be appointed Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 12 persons aged 18 - 65 receiving personal care. 15th November 2005 Date of last inspection Brief Description of the Service: 76/78 Hampstead Road is operated by the Brandon Trust. It is a registered care home for twelve younger adults with learning and/or physical disabilities. The property was purpose built to accommodate people with physical impairments. As the property is purpose built to accommodate people with physical impairments, there is level access and wide corridors. It blends well with its local residential environment and close to shops, park and bus routes. 76-78 Hampstead Road DS0000026628.V303263.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 two days in July and focused on the assessment of key standards of care. Records were examined and a tour of the premises took place to make judgements on the standards of care. As the residents have severe learning disabilities and profound needs and are therefore unable to communicate verbally directly, the interaction between residents and staff was observed. The members of staff on duty were consulted on the conduct of the home. What the service does well: What has improved since the last inspection? Since the last inspection, new devices have been purchased for two people because they are likely to have seizures at night. These sense movement and have replaced listening devices, which were more intrusive to the person. Equipment for residents that enjoy outdoor activities was purchased for these residents. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 6 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. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 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 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is adequate. The admission procedure must be clear about the process to ensure that the placements are suitable for the home. EVIDENCE: Within the Statement of Purpose is the criteria for admission at the home. It specifies the category of needs along with a brief description of the process. A reference to the arrangements for introductory and trial periods is incorporated. The registered manager prepared an in-house admission procedure and a Trust policy also exists Integrated within the procedures is a commitment towards ensuring that appropriate placements will be provided: however, the process followed for assessing the suitability of the person for accommodation at the home is not specified. The admission procedure must be clear about the process for ensuring that the placements are suitable for the home. It was understood from the acting manager and senior support worker that there is potential for one resident vacancy. Should a vacancy arise, the home will actively seek to fill the vacancy. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 9 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 in this outcome area is adequate. Individual care plans describe the actions to be taken to meet residents’ needs using a person centred approach. Care plans guide the staff on the individuals method of communication and this helps to empower residents. Daily records sheets must be linked to the progress of the care plans and must be more indepth. Risk assessments are completed for any activities that may involve an element of risk. EVIDENCE: Planning for Life Packs are in place for each person. They are separated into sixteen sections, which relates to all aspects of the persons life in a care home. The care needs that relate to personal details, contracts, care needs, daily records, assessments and care plans are included. Care plans contain the assessed needs and aspirations specifying the support to be provided with key 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 10 elements of a person centred approach. As the residents accommodated have severe learning disabilities and profound needs, the information is based on staff’s perception of the approach to be followed. Each assessed need describes the manner in which the need is to be met along with the anticipated outcomes. It is followed by an in-depth routine plan of action. For residents that are non-verbal, care plans detail the method used by the individual to express their perceived wishes, likes, dislikes. The gestures, vocal sounds and body movements are described with the perceived meaning and support to be provided. Within these plans is a brief account of the person’s level of understanding and provides guidance to enhance their understanding. The acting manager reported that six-monthly reviews took place in February 2006. In future it was stated that reviews will occur on a rolling programme. The review format in use seeks to confirm the views of the person, their representatives and significant others. The person’s needs for day care service is discussed and an action plans prepared. The acting manager then described the process for reviewing residents’ needs. Initially Keyworkers undertake monthly reviews, which can be forwarded to relatives, with copies kept at the home. Information from the monthly reviews is discussed at review meetings and from the review meeting care plans are updated. The staff use pre-prepared daily records that are specific to the person to report events. The format generally seeks information about meals, activities and personal care needs. It intends to demonstrate that residents are enabled to make choices. The information recorded is varied in terms of the activities and choices. The information recorded is basic, focussing on physical care tasks, with little bearing on the progress of the care plan. Members of staff giving feedback on consistency of care stated that during induction there are opportunities for staff to familiarise themselves with care records. They must sign to indicate their awareness of the Planning for Life Packs and during supervision residents needs are discussed. Keyworkers are expected to attend residents reviews and any changes are conveyed at staff meetings and handovers. Individual risk assessments for activities that may involve an element of risk are undertaken. The risk, options and effects are assessed and from the assessment a risk reducing plan and action plans are developed. The residents are not provided with front door keys or access to the first floor office. Generic risk assessments based on using the front door keys and access to the stairs are in place because it restricts residents freedom and choice. The effects of restricting residents freedom and choice were assessed 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 11 and reviewed with outcomes which are appropriate and related to the individuals needs. The home’s accident book was examined. Sixteen accidents and incidents were recorded since the last inspection. The record book is carbonated and copies are sent to the Trust office. Members of staff report within the record any follow-up action and actions to prevent reoccurrence, ensuring that for persistent incidents there is a trigger for staff to re-assess existing or develop risk assessments. For some reports, staff recorded that the risk assessments would be updated. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 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. Activities are based in-house and in the community although it is difficult to be clear about the amount of activity provided from the available documentation, the daily records are scant and require more detail about the activities. Members of staff ensure that residents are able to maintain contact with family and friends. Members of staff respect the individuals privacy, dignity and independence by routines and house rules. Residents have a varied and nutritious diet. Records of food provided must be up to date and all staff must be aware of the procedure for serving liquidised meals to further respect the individuals dignity. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 13 EVIDENCE: During discussion with the acting manager, it was understood that placing agencies have “cut” the day care services for residents placed by them. Consultation is taking place with them to ensure that residents can access community-based activities. Each house has an activity programme that lists the person’s daily activities. 1:1’s are scheduled with the person and their keyworker with other community activities, for individuals and small groups with not more than two people. Relaxing baths, Snoezelen sessions, massages and music are arranged inhouse. The staff, record in the individual daily records, the activities undertaken by residents: however the daily records are scant and require more detail about the activities. The acting manager described the current activities to enable residents social inclusion into the community. One resident uses the local Church and residents use the local amenities. It is intended to increase residents inclusion into the community and to achieve this aim, keyworkers will be consulted about activities for their key residents. Keyworkers will then enable residents to participate in these activities during 1:1 time. A review will then occur to ensure the activity is appropriate. Making and Maintaining Relationships is included within the individuals Planning For Life Packs. For some residents, maintaining contact with family and friends is essential and their action plans emphasise the importance of maintaining contact. However, the activities are not recorded in the activity programme or recorded in the daily records as taking place. The arrangements for visiting the home are specified in the Statement of Purpose. Visitors are welcome and can conduct their visits in the shared space or in private areas for additional privacy. There is a visitors book and generally professionals visitors record the date and nature of their visit to the home. Members of staff in house 1 stated that one relative visits family members and generally the resident will go out with their family. In house 2 staff stated that one resident has infrequent visits from family and these visits take place in the bedroom. Residents daily routines are included in their Planning for Life Packs. Routines for getting up, daytime and evenings are in place and specific. Within the 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 14 guidance the individuals rights likes and dislikes are incorporated. Members of staff were consulted about their responsibilities towards respecting the person. Members of staff felt that having no structured times to rise or retire or routines for completing tasks meant the person was treated as an individual. With the exception of one person residents have access to all parts of the building. For one there are restrictions imposed for entering the kitchen whenever staff are not present. Knocking on bedroom doors, ensuring residents are appropriately dressed and allowing residents to undertake tasks by the provision of aids and equipment, respect the individual. In terms of interaction with residents and not each other, members of staff stated that the activities and 1:1 sessions ensured that staff spent time with residents. Members of staff in house 2 stated that staff prepare the five-week rolling menus. The menus contain special instructions for particular residents. For example, low fat and to have meals cut in a particular way. The range of foods fresh, frozen and tinned foods kept in both houses reflected the menus. The daily records are not kept up to date for residents. There were instances where fluid charts and meals provided are not recorded particularly at lunchtime. There is a record of fridge and freezer temperatures kept at the home. However, the record in house 1 is inconsistently maintained and a record of cooked meats is not maintained in either house. Members of staff stated that their understanding of the person (for example, refusal to eat and their knowledge of the individual) ensures that the preferred meals are provided. Signs and assessments of the external environment are used to provide snacks and refreshments in between meals. In house 2 a member of staff explained the procedure followed for liquidising meals. It was explained that meals are liquidised and served in individual portions for residents on soft diets. In house 1 not all staff were aware of the procedure for serving liquidised meals. One member of staff had been liquidising the food together and serving the meal in one dish. One resident is having specific drinks in designated cups and it was understood that this empowers residents to make choices. The member of staff stated that this process had been tried without success on other residents. 76-78 Hampstead Road DS0000026628.V303263.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 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. A person centred approach is used to describe the actions for personal care, which incorporate key elements of rights, choice and independence. Members of staff monitor residents health care needs well and where necessary request referrals for specialist support. To develop safe systems of medications, staff must sign medication administration records immediately after administration. Where medications are concealed protocols must be followed and the compatibility must be discussed with the pharmacist. Records of disposal must be countersigned by the pharmacist or their representative to indicate receipt for disposal. EVIDENCE: The individual personal care needs are included within their Planning for Life Packs. Guidance for the staff to meet the assessed needs is specific and incorporates the likes, dislikes and preferred routines. A person centred 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 16 approach is used to describe the actions taken and incorporate key elements of rights, choice and independence. Information about the person’s appearance is recorded in their Planning for Life Packs. Where appearance is essential to the person, plans are specific and generally ensure that where possible residents are enabled to make choices. Health profiles are completed for each person, with a brief history of illnesses and diagnosis. A set format is followed and there are expectations that staff compile the profile on all health care areas, which include respiratory, allergies, continence, oratory and digestive. Health screening, medication and health checks are also incorporated. Where health checks are requested, staff complete a medical report. The reason for contacting the professional, the diagnosis, advice and treatment with follow-up action are all detailed. The support required from staff to access health services is detailed and because residents do not use verbal communication, staff must accompany residents with consultations. From the record of the health checks, it is evident that residents access NHS facilities. Dentist and optician visits are regularly arranged. Documentation from health care specialists is included and written confirmation of the visit is sent to the home. One person has a pressure sore and the care plan instructs staff on the actions to be taken. A member of staff explained the routine followed for this person and their confidence that staff have the skills to identify potential signs of deterioration was expressed. A monitored dosage system is used to administer medication at the home. During the inspection the medication administration sheets were examined and gaps were found, indicating that staff do not sign the records immediately after administering medications. It was also noted that members of staff were using jam to administer medication to one person. However, a local protocol that follows good practice guidelines is not in place for this person. Staff must ensure that procedures for concealing medicines are followed. Advice must be sought to ensure the medication is compatible with jam. Homely remedies administered from a stock supply when required are not administered are not kept at the home. When required medications are stored and recorded separately, with a running balance. A record of medications no longer required is maintained and staff reported that medications for disposal are collected from the home. The records are not, however, countersigned at all times by the pharmacist or their representative. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 17 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 18 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 & 23 Quality in this outcome area is adequate Records of complaints must be available for inspection at all times as this is a key mechanism to identify residents’ views about the service, even indirectly. Members of staff know the procedure for reporting poor practice. EVIDENCE: Residents are unable to voice complaints directly due to the profound nature of their disabilities. It was understood that staff advocate on behalf of the residents. However, there was no evidence of this as the complaints record book was not available at the home. Members of staff consulted during the inspection reported that statutory training that includes POVA training is provided during the induction programme. Members of staff expressed a clear understanding of their expectation towards reporting poor practice. 76-78 Hampstead Road DS0000026628.V303263.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. The home is clean and free from offensive smells. Although the general décor in the home is adequate, there are a number of minor repairs that require attention. Bedrooms are suitable to meet the individuals needs and lifestyles, toilets and bathrooms offer sufficient personal privacy. Shared space is safe and comfortable. EVIDENCE: Hampstead Road is purpose built to accommodate people with physical and sensory impairments that have learning disabilities. The accommodation is arranged into two separate dwellings, which is linked by shared space and office upstairs. There are six single rooms, lounge and kitchen/dinner in each house. Other shared space consists of a laundry, Snoezelen and activity room. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 20 It is located close to shops, places of worship, amenities and bus routes. The staff accompany residents and the home’s vehicle is used to access community facilities. The home was clean and free from offensive smells. Although the general décor is adequate, there are a number of minor repairs that require attention. For example, holes in the walls where previously there were shelves or fittings. In each house there is a bathroom, shower room and toilet with six room arranged into a circle. In house 1 there is a hi-lo bath disabled toilet and lowlevel sink. It was noted that there was a collection of equipment left around the room indicating a lack of storage space in the room. The toilet is suitable for a wheelchair user with sufficient storage for continence aids. The shower room is appropriate for residents that have mobility impairments. The ratio of bathroom is two bathrooms for every two residents and two toilets for every two residents. Bedrooms are single and lockable and members of staff ensure rooms are decorated to their perception of the individual. Bedrooms have furniture and fittings that reflect their lifestyle and needs. There is a lounge in each house and there is sufficient seating for the residents in the house to sit together. The laundry is away from both kitchens and shared by both housed. The walls are painted and there is vinyl flooring for easy cleaning. There are two small washing machines with specific programmes for sluicing and tumble dryers. One member of staff stated that one washing machine was recently purchased. 76-78 Hampstead Road DS0000026628.V303263.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is adequate. Staff personnel files are kept at the Trust office. A further inspection to check these records will take place in the future. Staff’s training records must be kept up to date to demonstrate competence to meet residents needs. EVIDENCE: Staff personnel files are kept at the Trust office and a checklist of the recruitment details is kept at the home. Managers’ are expected to view application forms, CRB disclosures on all staff and written references at the Trust office. The manager then completes a checklist for each person’s personal details, references and CRB disclosures viewed at head office. Although records for staff mandatory training are up to date, the staff on duty stated that the records of other training attended by the staff are not up to date. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 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, 41 & 42 Quality in this outcome area is adequate . Steps are being taken by the Trust to maintain a stable environment for residents during the recruitment of a manager. To maintain a safe environment, checks of emergency lighting and fire fighting equipment must be undertaken at the stipulated frequencies. The CSCI must be kept informed of incidents and accidents reportable through Regulation 37. Records of care and support including activities need greater detail in order to better demonstrate how the best interests of residents are promoted. EVIDENCE: The acting manager gave feedback about undertaking the role, it was understood that the purpose of the role was to keep both houses running. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 23 Maintaining stability for the residents was essential during the recruitment of a manager. An overlap between the appointed manager and acting manager will occur to ensure a smooth transition. The records that relate to fire safety checks and practices were examined. The records indicate that the staff undertake weekly checks of the fire alarm system and contractors undertake annual checks. It was understood from a senior support worker that fire training was arranged for the end of the month. Emergency lighting and fire fighting equipment checks are out of date and must be checked at the stipulated frequencies. It transpired during this inspection that the boiler had broken down between inspections and was not repaired for a significant period of time. From the notices found around the home during the inspection, it is evident that during the period the boiler was broken residents were at risk from scalding. It was understood from staff that hot water was coming out whenever the toilet was flushed and whenever cold taps were used. However, the Commission was not informed about events involving residents welfare through Regulation 37 notifications as is required in law. 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 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 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 1 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 2 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 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 x x 2 2 x 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 25 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. Standard YA24 YA41 Regulation 23(2)(b) 18 (1) (a) Requirement Attend to minor repairs to the property The staffing levels at night must be assessed to ensure members of staff can evacuate the home safely at night in the event of a fire (Not followedup at this inspection) Training records must be kept up to date. The manager must inform the Commission of incidents and accidents that affect residents welfare. To maintain a safe environment, fire equipment and emergency lighting checks must be undertaken at the stipulated frequencies. A record of complaints must be kept at the care home. a) Staff must sign medication record sheets immediately after administration, b) Where medications are concealed protocols must be followed, c) The pharmacist or representatives must DS0000026628.V303263.R01.S.doc Timescale for action 30/08/06 30/08/06 3. 4. YA41 YA42 18(1)(c), Sch 4.6(g) 37 30/08/06 30/07/06 5. YA42 13(4) (c) 30/08/06 6. 7. YA22 YA20 17(2), Schedule 4.11 13 (2) 30/07/06 30/07/06 76-78 Hampstead Road Version 5.2 Page 26 countersign records of disposal 8. 9. 10. YA17 YA17 YA6 12(4) (a) 16(2)(h) 15(2)(b), Sch.3 Temperatures of fridge, freezer and cooked meats must be consistently recorded Members of staff must be made aware of the procedure for liquidising meals. Ensure daily records contain sufficient detail about care and support provided, including activities, and that they link to care plans. The admission procedure must be made clear about the process to be followed. 30/07/06 30/07/06 30/08/06 11. YA2 14(1) 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 27 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 76-78 Hampstead Road DS0000026628.V303263.R01.S.doc Version 5.2 Page 28 - 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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