Inspection on 26/03/07 for 76 Bodmin Road

This inspection was carried out on 26th March 2007.

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

Other inspections for this house

76 Bodmin Road 28/03/06

76 Bodmin Road 14/09/05

76 Bodmin Road 02/03/05

76 Bodmin Road 01/06/04

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 Bodmin Road (76) 76 Bodmin Road St Austell Cornwall PL25 5AG Lead Inspector Kerensa Livingstone Key Unannounced Inspection 26th March 2007 01:00 Bodmin Road (76) DS0000008978.V298250.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 Bodmin Road (76) DS0000008978.V298250.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. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bodmin Road (76) Address 76 Bodmin Road St Austell Cornwall PL25 5AG 01726 74629 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) Mr David Roseveare Mrs Janet Roseveare Miss Lisa-Marie Shaw Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th March 2006 Brief Description of the Service: 76 Bodmin Road is a large detached house with three storeys, within walking distance of the centre of St Austell. The Registered Manager and partner live in with their daughter, a recent new addition to the family, providing personal care to four adults who have a Learning Disability, in a family style home. Since the last inspection a fourth service user has moved into the home. The Registered Providers live locally and visit the home several times during the week. There is a large garden and car park to the rear of the home with limited parking at the front. Access to the rear of the home is via a bumpy lane. Service User’s accommodation is provided on the first floor. On the ground floor there is a designated lounge with a dining table and chairs and conservatory for the service users. There are two other communal rooms predominantly used by the family, these are used for service users when visitors come. There is a large kitchen, one family bathroom with shower and toilet. There are opportunities for socialising and visitors are welcomed to the home. The home was observed to be clean, homely and tidy throughout. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short notice Key Inspection that took over a half-day inspection. The Inspector knows this home well having visited here for several years. The Inspector looked at record keeping, Policies and Procedures and the environment. The inspector met with two of the Service Users, as the other service users were attending full time day activities on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Service Users are provided with information about the home, this information should be reviewed and produced in a format that is suitable for the Service Users. A full needs assessment must be completed for all new service users to ensure that the home can meet their needs. All service users must have an up to date individual plan of care. Information about advocacy services should be provided and service users encouraged to manage their own finances with the individual support that they require. All records must be up to date and kept locked away to protect the service users right to privacy. Staff should enable service users to take responsible risks and action must be taken to minimise risks. Personal support is provided depending on service user’s wishes, preferred routines must be explored and recorded in the plan of care. The medicines in the home must be stored safely. Policies and Procedures must be up to date and developed to cover all aspects of safe handling of medicines. No staff are employed in the home, this situation must be reviewed to ensure that the service users needs can be met over a twenty-four hour period. No training has been provided for anyone caring for the service users. Staff must Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 6 have the specific skills and knowledge to meet the service user’s needs. Protection of Vulnerable Adults training is required and the procedures need updating. The Manager must ensure that with the increase in numbers to four service users, the opportunities for choice of leisure activities from the home are not lost. Food records must be kept. Service users enjoy living at the home and the lifestyle offered to them. There are important areas of management and administration that require urgent attention such as health and safety, training, quality monitoring and record keeping. The registered manager and persons working in the home must undertake regular training such as moving and handling, Foundation food hygiene, infection control, health and safety, infection control, fire training, first aid. No persons working at the home have undertaken any fire training or fire safety precautions. The inspector was informed that there is no fire risk assessment for the home, the Registered person must contact the Fire service immediately and discuss how they can address training, risk assessment and statutory checks within the home. Environmental risks assessments must be completed for risk factors in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bodmin Road (76) DS0000008978.V298250.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 Bodmin Road (76) DS0000008978.V298250.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service Users are provided with information about the home, this information should be reviewed and produced in a format that is suitable for the Service Users. A full needs assessment must be completed for all new service users to ensure that the home can meet their needs. Service Users are provided with written terms and conditions. EVIDENCE: The Statement of Purpose has been reviewed and reflects the services offered by the home, this was updated to include the fourth Service User. All Service Users have been provided with a copy of the Service User’s Guide. However the service user’s guide is not available in a format suitable for the service users e.g. language, pictures, video. On previous inspections there was evidence of a full assessment of needs for the existing Service Users prior to moving into their home. At this inspection there was no full assessment including the required information listed in National Minimum Standard (NMS) 2.3 for the newest service user. This information must be gathered prior to moving into the home and form the basis for the individual service user plan. Family carer’ interests and needs should be taken into account subject to the service user’s agreement. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 9 Prospective service users are invited to visit, meet the service users and look around the home. Emergency admissions are not considered at this home. The Service Users have contracts, which include terms and conditions with the Home, as well as Social Services contracts. These are signed by the Service User and make reference to the Service Users plan. It is recommended that these include the designated room for each service user. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. All service users must have an up to date individual plan of care. Information about advocacy services should be provided and service users encouraged to manage their own finances with the individual support that they require. All records must be up to date and kept locked away to protect the service users right to privacy. Staff should enable service users to take responsible risks and action must be taken to minimise risks. EVIDENCE: The Registered Manager must ensure that all Service Users have an individual plan, including any restrictions on choice and freedom, describing facilities and services to be provided by the home and current and changing needs and aspirations of the service user. This must be discussed with the Service User and/or family, friends or advocate and reviewed at least six monthly. One service user had no plan of care, the others require further development and updating. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 11 Service users are generally provided with support and help to enable them to make decisions about how they live their lives. No advocacy, peer support or self advocacy groups are involved with any of the service users. The Registered person must provide information and enable service users to access these services. Service users should manage their own finances, support and tuition should be provided and the reasons for these documented and reviewed. Currently the Registered Manager manages all the service users monies. The agent for the service user should be independent from the home. Service users enjoy living at the home and informed the inspector that they were free to make choices about how they spend their time. Service Users wishes and choices must be documented within their records, any risk management factors include how these are managed for example finances, mobility, outside the home. There were no risk assessments for any of the service users at the time of the inspection. Assessments had been conducted to demonstrate why service users should not have keys to their rooms or the home. The inspector and Registered Manager discussed the importance of service users being able to live an independent lifestyle offering support rather than limiting activity supported by the identification of risk. There is a lockable cabinet, however on the day of the inspection records were not stored there, in fact some records could not be located. All records must be accurate, secure and confidential. The Registered Manager has a clear confidentiality Procedure for the home. . Bodmin Road (76) DS0000008978.V298250.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users are afforded the opportunity to participate in a range of recreational and educative activities both inside and outside the home. The home adopts a ‘family style’ with routines and rules based upon individual choice. The Manager must ensure that with the increase in numbers to four service users, the opportunities for choice are not lost. Food records must be kept. EVIDENCE: Service Users attend a wide range of structured daytime activities e.g. Blantyre, College. On the day of the inspection three service users were due to attend day care activities. The activities participated in include college to do Information Technology, Fashion, Communications and Cooking. Other activities include creative workshop, drama, trampolining, swimming, games, painting, a local workshop to do woodwork, computers and cooking. One Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 13 service user informed the inspector how much they enjoy attending their daytime activities. Since the last inspection due to changing circumstances in the home, the leisure activities and trips out from the home have been taking place less frequently. Service users participate in the weekly shop and are able to help preparing meals. There was no holiday this year as there had been previously, day trips were offered instead. The inspector and Registered Manager discussed the value of keeping a centralised list of activities offered by the home to enable them to review the variety and uptake of activities on offer. Accompanied walks locally take place. The Inspector observed evidence of a range of leisure activities within the homes such as quizzes, music, sky television, jigsaws, scrabble and literacy games. One service user informed the inspector how they were able to choose whether to particpate in activities within the home or not. One Service User attends Church and visits the local library. Service users can telephone their family and friends or visit them at any time. Family and friends can visit the home at any reasonable time and service users are able to receive their visitors in private; in their rooms or the lounge. Service users decide who they see and who they do not see. One service user attends the Women’s Fellowship meeting and goes bowling. The menu is flexible and can respond to individual requests, in a family way. Service users have a variety of meals at the day centre and this is considered when organising the menu. Snacks and drinks are readily available. Special diets could be provided if required. Advice has been provided about healthy eating and exercise. Service users help to choose and prepare their food. Special meals are provided for occasion such as birthdays and Christmas. Nutritional preferences and food records must be recorded. The Registered Manager’s food hygiene certificate expired last December. All staff preparing food must undertake this training and it is recommended that the person preparing the majority of meals undertakes further training. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 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. 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. Personal support is provided depending on service user’s wishes, preferred routines must be explored and recorded in the plan of care. Health and personal care needs appear to be met. The medicines in the home must be stored safely. Policies and Procedures must be up to date and developed to cover all aspects of safe handling of medicines. EVIDENCE: Service users are provided with personal support depending on their needs and wishes. This was confirmed by talking with service users. The Service Users individual plan must demonstrate that personal care and support is planned depending on the Service Users wishes e.g. times for getting up, going to bed, flexibility of meals and preferred routines. The inspector was informed that Service users are offered a minimum of an annual health check. There is evidence that health care needs are supported and professional advice support sought as required. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 15 There is a lockable facility for the storage of medication, however on the day of this inspection it was located in the kitchen, in a basket. Medication must be locked away in adherence with the home’s procedure. The inspector and Registered Manager discussed the benefit of printed medication administration sheets and suggested that this is discussed with the pharmacist. If handwritten sheets are to be used they must be signed and should be checked against the prescription by a second person for accuracy, then countersigned. There is only one Service User prescribed medication currently, who has expressed a wish not to retain and administer their own medication. There is Policy and Procedure for the Safe Handling of Medicines, this requires updating, as medicines are no longer stored where stated and requires further development to include all aspect of the safe handling of medicines as detailed in National Minimum Standard (NMS) 20. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are aware of who they can express their concerns to. Protection of Vulnerable Adults training is required and the procedures need updating. There have been no complaints or concerns expressed about this home. EVIDENCE: The Commission have received no complaints in respect of this home. No complaints have been received within the home. No record is kept of any concerns or low-level complaints. A Complaints Procedure has been written that includes time frames and should be updated to include the Department of Adult Social Care. There are regular informal opportunities where feedback is gathered regarding outings, food. The service users are aware of whom they can speak to if they have concerns. There are Policies and Procedures within the home for the Protection of Vulnerable Adults that includes Whistleblowing, these require updating. The home has information about ‘No Secrets’ and definitions of Abuse. The registered manager and partner have not attended the Protection of Vulnerable Adults training provided by Cornwall county council, it is recommended that they do this. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home’s physical environment is comfortable and homely, it is suited to the Service Users needs. Individual accommodation should include the required fittings and furnishings. Environmental risk factors must be assessed and minimised. EVIDENCE: The home provides a safe, comfortable, homely environment that is free from offensive odours. Generally the home was clean, however there were areas which required dusting. There is adequate lighting and ventilation. On the day of the inspection the home was noted to be quite cool, however there are free standing heaters if needed. Environmental risk assessments must be completed if these are to be used. A new room has been provided since the last inspection, the windows in this first floor room are not restricted. It is recommended that advice is sought from the Environmental Health officer regarding this and environmental risk assessments must be completed for any risk factors in the home. There must also be evidence of ongoing maintenance Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 18 and renewal of fabric in the other service user’s rooms. There is easy access to local amenities. Service users rooms are single, furnished and personalised in accordance with their individual preferences. The service user’s bedrooms are personalised and provide adequate space for them to pursue their interests, there is supplementary communal space. The fourth room is lockable, however the service user does not have a key. The other three rooms should be provided with a lock with an override device, which is only used as indicated by a service user’s risk assessment. All rooms should provide the items listed in NMS 26.2 e.g. two comfortable chairs, lockable storage space, wardrobe, suitable bed linen, shelving, chest of drawers etc. There is a lounge with a dining area and a conservatory that is specifically for the service users. There is another lounge which can also be used for visitors or sitting watching television with the family. There is a spacious kitchen for shared activities and private use. The Service Users attend the Blantyre Centre, therefore are rarely all at home together during the week. No Service Users use a wheelchair. There is a garden to the rear of the home. No specialist equipment or environmental adaptations are required, however these would be provided on an individual basis as required. The registered manager is sensitive to the age and gender diversity of the service users and strives to meet these needs. The home was observed to be generally clean and very homely on the day of inspection. There is a written Infection Control policy and a resource file with local health information, these require keeping up to date. The laundry facilities are situated in the kitchen. Dirty laundry is transported in a container with a lid directly to the washing machine. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. No staff are employed in the home, this situation must be reviewed to ensure that the service users needs can be met over a twenty-four hour period. No training has been provided for anyone caring for the service users. Staff must have the specific skills and knowledge to meet the service user’s needs. EVIDENCE: No staff are employed at the home. However with the fourth service user, the Registered Manager and inspector discussed the need for a rota to demonstrate who is on duty during the day, as it will not be possible for the Registered Manager with changing circumstances to provide all the cover. All family members have completed Criminal Records Bureau checks. The Registered Manager is aware of the need for Service Users to be supported by competent individuals who undertake regular training. No training has been undertaken over the last year. There is no training and development plan for the staff working within the home. Staff must have the skills and experience necessary to meet the service users needs e.g. specialist skills and knowledge Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 20 to client group. Fifty per cent of the staff should have a National Vocational Qualification level 2 in care. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users enjoy living at the home and the lifestyle offered to them. There are important areas of management and administration that require urgent attention such as health and safety, training, quality monitoring and record keeping. EVIDENCE: The Registered Manager is undertaking her National Vocational Qualification Registered Managers Award and plans to commence her National Vocational Qualification Level 4 in care. No training has been undertaken since the last inspection. The Registered Providers visit the home regularly. There is no quality monitoring systems or annual development plan. Views of stakeholders, friends and family should be sought on how the home is achieving goals for service users. Previously feedback had been gathered from Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 22 the Service Users and recorded in a diary and/or a meeting held to discuss issues, this has lapsed. Policies and Procedures require updating. The Visitors Book was not available on the day of the Inspection; the Registered Manager must keep a record of all visitors to the home. Records must be kept in a locked cabinet. The need for daily records to be available rather than stored on a computer where discussed at the previous inspections and the legal status of the records was reiterated at this inspection. The inspector was informed that there is no fire risk assessment for the home, the Registered person must contact the Fire service immediately and discuss how they can address training, risk assessment and statutory checks within the home. Fire posters are placed in each room to advise service users of the action to be taken. Hot surfaces are uncovered, hot water is unregulated and windows are not restricted. Environmental risks assessments must be completed for these and any other risk factors in the home. Advice should be sought from the Environmental Health Officer and evidence available for inspection. No persons working at the home have undertaken any fire training or fire safety precautions. All staff must be provided with the required training such as moving and handling, Foundation food hygiene, infection control, health and safety, infection control, fire training, first aid. There is evidence of reinvestment in the home. The Registered Providers must provide evidence of financial viability as part of the routine annual inspection process. Employer’s Liability insurance is in place and must be posted on the wall. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 2 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 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 1 3 Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 24 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 YA2 Regulation 14 Requirement Timescale for action 01/08/07 2. YA9 13(4) 3. 4. YA10 YA17 17(1b) 16(2i) 17(2) Sch. 4 The registered person shall not provide accommodation to a service user at the care home unless, so far as is practicable to do so needs of the service user have been assessed, the registered person has a copy of the assessment and the registered person has confirmed in writing to the service user that the care home is suitable for the purpose of meeting the service user’s needs. The registered person shall 01/06/07 ensure that unnecessary risks to the health or safety of the service users are identified and so far as possible eliminated and any activities in which service users participate are so far as practicable free from hazards. The registered person shall 01/06/07 ensure that the records are kept securely in the care home. The Registered person shall 01/08/07 provide in adequate quantities suitable, wholesome and nutritious food, which varied and properly prepared e.g. foundation food hygiene DS0000008978.V298250.R01.S.doc Version 5.2 Bodmin Road (76) Page 25 certificate, food records. 5. YA20 13(2) The Registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home e.g. safe storage, procedure. The registered person must ensure that the persons employed by the registered person to work at the care home received training appropriate to the work they are to perform e.g. NVQ in care, specific skills and knowledge. The registered person must ensure that there are at all times suitably qualified, competent and experienced persons working at the home in such numbers as are appropriated for the health and welfare of the service users. This must be demonstrated on a duty rota. The registered person must ensure that the persons employed by the registered person to work at the care home received training appropriate to the work they are to perform and suitable assistance for the purpose of obtaining further qualifications appropriate to such work. The Registered Person shall establish and maintain a system for reviewing and improving the quality of care provided at the care home. The Registered person shall supply the Commission with a report in respect of any review conducted and make a copy available to the Service Users. Previous timescales not met 01/06/06 01/06/07 6. YA32 18(1c) 01/08/07 7. YA33 18(1a) 17(2) Sch. 4 01/06/07 8. YA37 18, 9 01/08/07 9. YA39 24 01/08/07 10. YA41 17(2) The registered person shall DS0000008978.V298250.R01.S.doc 01/06/07 Version 5.2 Page 26 Bodmin Road (76) Sch. 2, 3 &4 11. YA42 13(4) 12. YA42 23(4) 13. YA43 25(2) maintain for each service user the information and records specified in Schedule 3 and care home records detailed in Schedule 2 and 4 e.g. service users records, daily record, food records, risk assessments, duty rota. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated and all parts of the home are so far as reasonably practicable free from hazards to their safety. The registered person shall take adequate precautions against risk of fire, provide means of escape, make arrangements for training and by means of fire drills and practices make all aware of the procedure to be followed. Advice to be sought from the fire service and CSCI to be notified when this is done. The Registered Persons shall provide the Commission with evidence of financial viability and Employer’s Liability insurance. 01/06/07 26/03/07 01/08/07 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 YA1 Good Practice Recommendations For the service users’ guide and other information about the home to be available in formats that are suitable for the people for whom the home is intended i.e. appropriate languages, pictures, video etc. For the home’s pre assessment to include the items listed in NMS 2.3. For the Service user to manage their own finances and if DS0000008978.V298250.R01.S.doc Version 5.2 Page 27 2. 3. YA2 YA7 Bodmin Road (76) 4. 5. 6. 7. 8. 9. 10. YA7 YA14 YA18 YA22 YA23 YA26 YA35 this is not possible the service user’s agent/appointee to be independent from the home. For information to be made available about advocacy and self-advocacy groups. For service users as part of the contract price to have the option of a seven day holiday which they help to choose and plan. For the preferences and choices of the service users to documented in their plan of care. For a record to be kept of all low-level complaints or concerns. For the Registered Manager and other staff in the home to attend the externally facilitated Protection of Vulnerable Adults training. The service user’s room should promote independence e.g. door lock, lockable space, wardrobe For there to be a staff training and development plan based upon a training needs assessment. Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bodmin Road (76) DS0000008978.V298250.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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