Inspection on 14/05/08 for 87 Church Road

This inspection was carried out on 14th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

87 Church Road 15/07/07

87 Church Road 29/01/07

87 Church Road 30/08/06

87 Church Road 25/11/05

87 Church Road 24/06/05

87 Church Road 03/08/04

87 Church Road 27/04/04

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 27/09/2008.

CARE HOME ADULTS 18-65 87 Church Road 87 Church Road Frampton Cotterell South Glos BS36 2NE Lead Inspector Jacqueline Sullivan Key Unannounced Inspection 14th and 16th May 2008 10:00 87 Church Road DS0000003341.V360511.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 87 Church Road DS0000003341.V360511.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. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 87 Church Road Address 87 Church Road Frampton Cotterell South Glos BS36 2NE 01454 250028 0117 9709301 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Julie Egan Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8), Physical disability (8) of places 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 8 persons aged 18 years and over with learning difficulties who may also have physical disabilities. This may include persons age 65 years and over. May accommodate 1 named person with acquired brain injury Date of last inspection 15th July 2007 Brief Description of the Service: Aspects and Milestones Trust, a non-profit making organisation, operate the Home. The building is an extended, large bungalow that can accommodate up to eight residents with learning disabilities and physical disabilities. This may include residents 65 years and over. The Home is currently accommodating eight residents who are over the age of 55 years. The Home is located in a semi-rural area approximately seven miles from Bristol City centre. There are local shops within walking distance of the home. Transport is required to enable residents to access facilities further from the Home. There is Home transport, but taxis are used for residents who need to travel in their wheelchairs. All bedrooms are single occupancy and have washing facilities and a call alarm. There is a bathroom with assisted bath hoist and a separate walk in shower room. Shared space consists of a lounge, dining room and conservatory. There is a patio and garden area that is fully accessible to residents. The fees charged for staying at the Home are £869.05 a week. The aim of the home is to provide a person centred service. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The inspection took place over two afternoons. Surveys were received from residents, staff members and placing authorities. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the staff on duty. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for five of the individuals were reviewed. Residents and staff were also spoken with. What the service does well: The staff team have worked hard to provide a homely environment for the residents. Relationships between the residents and staff team are warm and friendly. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The residents would have more information about the home if the statement of purpose and service users guide were reviewed and all residents and their representatives received a copy. The resident’s needs would be better met if the registered person ensures that there is a system in place to ensure that the staff are qualified to an appropriate standard. The residents would have a more enjoyable and meaningful day if in-house activities for the residents were further developed. New residents would be better protected if the staff team ensures that the rooms they will occupy are safe prior to their admission to the home. The residents would be better protected if the staff team ensures that they are given their correct medication at all times. The resident’s environment would be improved if the bathroom cabinet were put up in the bathroom and the conservatory were a comfortable temperature for them. The residents would be more assured that their needs are being met if the registered person ensures that the residents changing needs are reflected in their care plans. The residents would be more assured that their needs would be met if a pre admission assessment is carried out and is available in their care files. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 7 The residents would be more assured that the staff team have the knowledge they need to assist them if all staff completed a relevant induction program. The residents would be better protected if all occurrences and situations that have an effect on the wellbeing of residents were reported promptly to the Commission for Social Care Inspection. The residents would not have to sometimes share their living spaces if the registered person considers another room for the office in the home. The residents would be more assured that the staff team are working consistently if staff meetings took place at more frequent intervals. The residents would know that any complaint they make would be acted upon quickly, if there had been a record that complaints have been resolved in the appropriate timescales. 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. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents do not have sufficient information in the statement of purpose and service users guide to make informed choices. There was not sufficient information about the newest resident admitted to the home for the staff team to be clear about this residents needs. EVIDENCE: Neither the statement of purpose nor the service user guide held at the home had sufficient detail to ensure that existing and prospective residents have the information they need to make choices about the home. It must be reviewed to include details of emergency admissions and include all the required information. The newest resident at the time of inspection had been admitted as an emergency and it was not clearly recorded if she and her representatives had received a copy of the service users guide. The service users guide is a large book with lots of pictures of the home and the residents. It is kept by the front door so residents and visitors can easily see it. However, the residents do not have a lighter, more portable copy they could take to their rooms, should they choose to read it there. Their representatives also do not have any other access to this information other 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 10 than the copy in the home. Some of the pictures of the residents need to be updated as some the residents pictured in the book have left the home and others have joined the home. The most recent resident had not received a copy of this document. One person was admitted to the home in the last year. This was on an emergency basis. Therefore there was no opportunity for this resident to “test drive “ the home. The information about this resident was sparse in that there was a temporary care plan and it was not clear who had written some of the information available. The minutes of a Meeting to discuss this persons needs, that the staff team stated had taken place, were not available. Whilst it is noted that information about emergency admissions can be delayed due to the nature of the admission. The gaps must be resolved promptly. There was a requirement about pre admission information not being complete made at the last inspection. This requirement will be remain until there is a full assessment of need for this resident. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident’s needs would be better met if their care plans reflected their changing needs. The residents can be assured that the staff team listens to their views, as they are encouraged to make choices and decisions about the way they wish to live at the home. The residents would be better protected if improvements were made to the risk assessments. EVIDENCE: Care plans were seen to be in place for all the residents. The deputy said that the manager is reviewing each of the plans. Those seen were large documents, which were detailed and included information personal history and information about their physical and mental health history, as well as about family and 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 12 friends. There was a plan of care to address the resident’s physical, mental, and social, needs. However the plans were not consistently updated to reflect the changing needs of the residents. For example, one resident had recently had a change of medication, which changed his behaviour. The staff were able to describe these positive changes but there was not a new action plan on this residents care plan to demonstrate how the staff will now meet his needs. Other information in the plans was not complete. For example the key ways that staff members communicate with residents. Discussions with three residents and evidence in their care files confirmed that resident’s choices and different preferences are respected. For example, they got up at different times during the morning; make choices about the food they would like to eat, and the clothes they wished to wear. A senior member of staff said that the residents chose the sofas in the lounge. Resident meetings were mostly monthly and showed that the residents are consulted about their care. Risk assessments were seen to be in place to support residents to be encouraged to live an independent and fulfilling life. These are reviewed and updated on a regular basis. However, these assessments would benefit from being reviewed to include the degree of risk. The most recent resident did not have a completed risk assessment in relation to the risk of her leaving the house. The staff had identified this risk but this must be formalised into a risk assessment detailing strategies to protect the resident and identify the degree of risk. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a choice of healthy meals. Resident’s rights are respected by the staff team. The residents would be more involved in meaningful daytime activities if these were consistently provided. The residents have regular contact with family members and friends. EVIDENCE: The residents spoken with explained that they choose the food for their meals and each had their favourite foods on the menu. The meals seen on the two days of inspection were well presented and healthy. The menus showed that the residents could have an alternative choice of food if they so wish. Three residents spoken with said they enjoyed the food. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 14 The range of activities available to the residents was inconsistent. The more able residents attended activities and day care services but the less able residents appeared to have long periods of inactivity either in their rooms or in the lounges. The records of activities showed that external activities take place. For example skittles group, trips to the theatre and a boat trip. One resident said she particularly enjoyed “Going to Weston on the train”. Residents who wish to, do attend church. However, the In house activities need to be developed further. As, it was seen over the two days of inspection that there were several times during the day where a resident was sitting in exactly the same position in the lounge by themselves with no activity in place. In this resident’s care recording it is stated that he likes gardening. However he has little opportunity to do so as the person who explored this interest with him has left the home. Another resident, whom a staff member said liked to listen to music in her room, was seen in the same position in her room several times during the day. There was no evidence in the daily recording that the staff team are regularly checking this is the resident’s choice or offering alternative choices. The manager is aware that the in house activities need to be reviewed as he says they happen on an “ad hoc” basis. A requirement has been made that the residents are consulted about the activities they would like to do during the day and that there is a plan of regular activities in place. These must be reviewed regularly. The staff team were seen talking respectfully to the residents and it was seen that they knocked on the resident’s bedroom doors prior to entering their rooms. Discussions with residents and staff members and evidence in the residents care records confirmed that the residents have regular contact with family and friends. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The resident’s health needs would be better met if the staff team consistently gave them the correct medication. The residents are able to choose how they receive personal support and how their health needs are met. EVIDENCE: In March 2008 a resident was given another resident’s medication. On two occasions a resident was not given their medication- once in March 2008 and once again in June 2008. In April 2007 there were medical errors in relation to four residents. This particular issue did not come to the attention of all senior managers until the end of the month, as it is the practise at the home for statutory notifications to be examined then signed off at the end of the month. Then they are sent to the Commission. This also means that the Commission is not receiving these notices promptly. In order to protect the residents this system must be reviewed. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 16 At the time of inspection there were no clear medical error procedures or evidence that this issue had been addressed at supervision with the members of staff involved. In May 2008 the Trust completed a spot check of the medication procedures. They found errors in the administration of medication to the residents. As a result, medication error procedures were instigated and an investigation initiated by the area manager. A requirement has been made that there is a system in place that ensures that residents are always given the correct medication. The findings of the investigation must be sent to the Commission so we can be clear what plan is in place to ensure that these errors do not take place. The administration of medication to the residents will be a focus of the next inspection. Health action plans are available for all residents. All the residents are registered with a general practitioner. Advice and support is available from a psychiatrist about residents with particular needs. Care reviews are held in the Home. These include the residents, staff from the home and sometimes the psychiatrist, and social workers. Evidence in the residents care plans confirmed that their physical and emotional health needs are met in the way that is preferred by them as there is a list of their likes and dislikes within these plans. The health records seen confirmed that staff monitor and observe the health of residents and call the doctor, if they are concerned about the person. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents are protected from abuse or harm. The residents can be confident their views are listened to and acted upon by the staff team. EVIDENCE: There was recorded evidence that all the residents had been given a copy of the complaints procedure and that the staff had explained to them how to complain if they so wished. Evidence in the complaints file confirmed that residents complain but the recording should be developed to ensure there is evidence that the complaint is resolved in the appropriate time scales and to the resident’s satisfaction. Three residents stated they knew how to complain if they wished to. One resident said, “If I am unhappy I would go and tell the staff.” She said that she felt the staff would sort out any problem she may have. Some staff have received Protection Of Vulnerable Adults training and there is a plan for the newer staff to receive this training. There are policies and guidance information about protecting vulnerable adults from abuse. Staff spoken with were able to demonstrate knowledge of POVA (protection on vulnerable adults) procedures. Residents who were spoken with confirmed that they feel safe in the house. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 18 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While residents enjoy a comfortable, clean and homely environment, those who spend considerable parts of their day sitting in the conservatory would be more comfortable if the temperature was better regulated. The residents enjoy bedrooms suit their lifestyles and needs. The residents would have more use of their shared spaces if the office were relocated. EVIDENCE: 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 20 87 Church Road is a purpose built bungalow set in a quiet residential area near to the village of Frampton Cotteral. It is close to local shops and residents use the local amenities. There are two lounges, and an adequate sized dining area for the residents to use. The choice of two lounges means that residents can choose where they sit. One area is a conservatory. The dining room has been refurbished to look more homely. The lounge, shower room and laundry room have recently been painted. New crockery that matches, a DVD player, a TV and a fridge have been recently purchased. There is a bathroom with assisted bath hoist and a separate walk in shower room. This helps residents with reduced mobility to meet their personal hygiene needs more easily. There are toilets, and a shower and bathroom located close to bedrooms, which is convenient for residents. These were seen to be clean and hygienic. The resident’s bedrooms were seen to be personalised and comfortable. The bedrooms were clean and tidy, and the standard of the decoration and the quality of the fixtures and fittings was satisfactory. Bedrooms do not have ensuite facilities. Whilst the staff team have put a lot of effort into improving the home there are some areas that need to be developed further. In that, it was seen that several residents spend a considerable part of their day in the conservatory. Over the two days of inspection the blinds in the conservatory were often shut. A staff member explained that this is because the room gets too hot for the residents to sit there comfortably. The closed blinds prevented the resident seeing the garden and made the room dark. A member of staff stated that airconditioning in this room would benefit the residents. It is required that the registered person ensures the residents can enjoy the benefits of sitting in the conservatory comfortably. The residents would benefit from a bathroom cabinet being put up in the bathroom; a staff member said that the house has been waiting for this to be done for several months. This senior stated that she would welcome more office time than the two days she has. The office is extremely small and difficult for more than two of the staff team to work in the space. This means that office tasks that involve more than one or two people take place in the resident’s communal spaces. A recommendation has been made that the registered person investigates other sites for the office in the home. In the office, the supervision records were kept in a locked cupboard. However this cabinet was not totally secure. There was an alleged incident involving 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 21 some members of staff several months ago whereby entry to the cabinet was forced. It is therefore required that a new more secure cabinet is purchased. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 22 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): 32,35 and 36. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The resident’s needs would be better met if the staff team completed their inductions more promptly and there were a system in place to ensure that all staff are appropriately trained. Residents would be more assured the staff team are working consistently if the frequency of staff supervision between the manager and deputy were more frequent. EVIDENCE: The recruitment procedures could not be reviewed at the inspection. Aspects and Milestones Trust keep some of their staff records at its head office. We carry out regular checks of staff employment files at the head office to ensure the Trust follows safe recruitment practises that protect residents. There are twelve staff members including the senior and manager, the majority of whom are new to the home. As the manager states in the pre inspection information “we have employed a virtually new staff team.” Many of 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 23 whom are new to the field of learning. We have had to divert an excess of time to their induction”. All new staff had started the detailed and informative induction programme. The manager had reviewed the induction and had included additional tasks to be completed. Whilst this meant the induction was extremely thorough it also meant that many of the staff were still doing the induction many months after starting. One staff member has been doing their induction for over a year. This point was raised in staff meetings where some staff felt that the length of time it took them to complete the induction was too long. They were unable to receive the additional payment for completion of the induction. Apart from the senior and the manager none of the staff team are appropriately qualified. None have a NVQ (national Vocational Award) in care or LDAF (Learning Disability Learning Framework) training. The senior stated that one person is registered and one person will start the course in June 2008. It is required that the registered manager ensures that there is a plan in place to ensure that all staff members complete this qualification. The staff training records showed that all staff have completed food hygiene training as required at the last inspection. Training includes epilepsy and supporting older people with a learning disability. Discussions with staff members and evidence in the supervision records confirmed that there was regular support and supervision provided by Mr Chard and the deputy manager. However the frequency of supervision for the deputy manager was infrequent with a gap of several months. The staff meetings minutes record was looked at. These showed staff meetings take place on an irregular basis. As this is a new staff team it is recommended that these meetings are more frequent to ensure the staff team are working consistently to meet the needs of the residents. It was noted that there was a team day in January 2008 and that another is planned in July/August 2008. A senior member of staff has reorganised all the administrative systems so they are more organised and accessible. Staff members spoken with found these systems easy to use. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 24 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, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s live in a Home that is adequately managed. However residents best interests have not always been safeguarded due to the delay in reporting serious occurrences to the Commission for Social Care Inspection. Residents’ health and safety is would be better protected if the staff team ensured that new residents bedrooms are made safe prior to their admission. Residents can be confident that their views are listened to by the staff team. EVIDENCE: Mr Chard is a qualified learning disabilities nurse. His career record showed that he has a number of years of experience working with residents who have learning disabilities. Prior to this employment he was employed primarily in a hospital setting supporting people with a learning disability. He was 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 25 registered with the Commission for Social Care Inspection as the manager in January 2008. The Deputy stated that Mr Chard and herself have very different managerial approaches. The Deputy prefers a more system based approach and is organising the systems within the home. As previously stated, whilst the staff supervision is regular, the communication and frequency of supervision between the managerial team is infrequent. With a new staff team communication between these key staff is very important. The monthly monitoring visits of the Home that must be carried out by a representative of The Trust are being undertaken as required by law. There are records of these visits being sent to the Commission for Social Care Inspection. The records that have been seen, demonstrate that the designated individual responsible for the visits spends time consulting with residents and their representatives and observing staff. At the last inspection a requirement was made that occurrences and situations that have an effect on the wellbeing of residents need to be reported promptly to the Commission. This is a requirement that all care homes must follow, and is often referred to as reporting under Regulation 37. This is the regulation that this refers to, and reporting is way for the Commission to monitor resident’s wellbeing in Care Homes. It was evident at that inspection that from March 2007 to July 2007 there were a number of incidents in the Home that should have been reported earlier to the Commission. Comments have been made else where about the continued delay in the notices reaching the Commission due to the system in place at the home. Consequently a second requirement has been made. Discussions with staff members and evidence seen in their files confirmed that staff undertake regular training in health and safety matters including first aid, and moving and handling practices. All staff that prepare and cook food for residents were able to demonstrate that they can do this competently and safely as they have been trained to do so. This is to protect the health and safety of residents. However the safety of the residents could be further improved. The most recent resident fell out of the bed in their bedroom room because the bed had been raised for the previous resident and had not been lowered for this resident. The resolution was to have a crash mat in place. But once the staff team realised that bed was too high and it was lowered to its original height there were no further falls. The staff team must ensure that beds, if raised, are lowered prior to the arrival of new residents so as not to put the residents safety at risk. 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 26 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X 2 2 X 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5(1)a-f; (2). Requirement The registered person ensures that the service users guide is reviewed and that all residents and their representatives receive a copy. The registered person ensures that the statement of purpose is reviewed so that it contains all the required information in schedule one. All residents and their representatives must be able to receive a copy on request. The registered person ensures that all new residents must have a pre admission assessment carried out so that they, and the Home know how their needs are going to be met. This is a repeat requirement. Timescale of 16/7/07 not met. The registered person ensures that the resident’s changing needs are reflected in their care plans. The registered person ensures that people using the service should have meaningful daytime activity. DS0000003341.V360511.R01.S.doc Timescale for action 01/11/08 2. YA1 4 (1)(c.) Schedule 1 01/11/08 3. YA2 14. 01/11/08 4. YA6 15(1). 15(2)c 16(n). 01/11/08 5. YA12 01/11/08 87 Church Road Version 5.2 Page 29 6. YA36 18(2) 7. YA20 13(2) The registered person ensures that the frequency of staff supervision between the manager and deputy is more frequent. The registered person ensures that there is a system in place to ensure that the residents receive the correct medication. The registered person ensures that there is a medication error procedure in place. The registered person ensures that the findings of the investigation conducted by the Trust are sent to the Commission. 01/11/08 01/08/08 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 30 8. YA24 23(1);(2)(a)(l)(p) The registered person ensures that: the bathroom cabinet is put up in the bathroom; the cabinet for storage of confidential documents is replaced and the conservatory is a comfortable temperature for the residents 19(5b). The registered person ensures that there is a system in place to ensure that staff are appropriately qualified. The registered person ensures that all staff must complete a relevant induction program so that they understand what their duties and responsibilities, and how they support and assist residents. This is a repeat requirement. Timescale of 16/08/07 not met. All occurrences and situations that have an effect on the wellbeing of residents need to be reported promptly to the Commission for Social Care Inspection. This is a repeat requirement. Timescale of 16/07/07 not met. The registered person ensures that the residents rooms are safe for new residents. 01/11/08 9. YA32 01/11/08 10. YA32 18(1)(a)(c)(i) 01/09/08 11. YA41 37. 01/11/08 12. YA42 13(4)(c). 01/11/08 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 31 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 The registered person ensures that there is a record that complaints have been resolved in the appropriate timescales and record whether the resolution was to the resident’s satisfaction. The registered person ensures that staff meetings take place at more frequent intervals. The registered person considers another room for the office in the home. 2. 3. YA32 YA28 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 87 Church Road DS0000003341.V360511.R01.S.doc Version 5.2 Page 33 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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