Inspection on 15/07/07 for 87 Church Road

This inspection was carried out on 15th July 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

87 Church Road 14/05/08

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 08/07/2008.

CARE HOME ADULTS 18-65 87 Church Road Frampton Cotterell South Glos BS36 2NE Lead Inspector Melanie Edwards Key Unannounced Inspection 15 July 2007 09:30 87 Church Road DS0000003341.V337397.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.V337397.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.V337397.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 87 Church Road Address Frampton Cotterell South Glos BS36 2NE 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) 01454 250028 0117 9709301 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.V337397.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 29th January 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. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over one day, a Sunday. Please note some residents have verbal communication difficulties. The inspector met all of the eight residents currently living at the Home. Four support workers were consulted about their roles and responsibilities, training needs, and how they assist and support residents. Staff were observed assisting residents with their needs. A portion of lunch was sampled in the company of a small group of residents, at their invitation. A selection of records relating to the day-to-day running and management of the Home were inspected. A sample of resident’s care records and care plans were also reviewed. The environment was seen throughout, inside as well as the garden area. The Home was operating within the required conditions of registration set down by The Commission. The conditions of registration detail the type of care and the needs of residents, as well as the numbers of residents who may stay at the Home. However the certificate of registration was not accurate as it has the name of the previous registered manager on it. What the service does well: What has improved since the last inspection? The Home has recruited a number of new staff who are kind, caring and well liked by the residents. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 6 There is now a first aid box in the kitchen to protect staff and residents’ health and safety. Menu records are now more detailed and demonstrate residents are provided with a varied and well balanced diet. 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. The summary of this inspection report can be made available in other formats on request. 87 Church Road DS0000003341.V337397.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 87 Church Road DS0000003341.V337397.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.Quality in this outcome area is poor. Residents’ needs are not fully assessed prior to admission. This may have an impact on how residents’ needs are met by the Home. Residents and their representatives are provided with information to make an informed choice about living at the Home. Residents are not given the opportunity to visit the Home before admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide and the statement of purpose were read. Each resident and their families are given their own copy of the guide so they have access to helpful information about life in the Home. The service users guide and the statement of purpose include information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is also in both documents. The complaints procedure is in the document for residents to know how to complain about the service. There are a number of pictures of the Home, and community included in the service users guide to help inform the reader about the service. The use of photographs gives the reader of the service users guide very helpful information about the home and community it is in. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 9 To find out how residents’ care needs are assessed and how the care they need is being planned, one resident’s assessment records were looked at in detail. There was no evidence that prior to the persons admission to the Home in December 2006, that a pre- admission assessment had been completed to show how the Home were going to meet the persons needs. However there was an assessment of the residents’ physical, social, psychological, and communication needs that had been completed after the person had lived at the Home for several months. It had been reported by staff that the resident concerned had not had the opportunity to ‘test drive’ the Home by coming for a visit before they moved in. This should not be repeated except in the rare situation of an emergency admission. It is very important that prospective residents are given the chance to visit a Care Home before they move in to see what they think of it. 87 Church Road DS0000003341.V337397.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. Quality in this outcome area is good. Residents’ needs are assessed, and care plans show how to meet their needs. Residents are supported to make decisions and to take risks in their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how effectively residents are being supported to meet their needs one care plan was read. There was a personal profile completed about the person. This included their personal history and information about their physical and mental health history, as well as about family and friends. There was a plan of care to address the resident’s physical, mental, and social, needs. The care plan generally aimed to promote the independence of the person in their daily lives. The care plan had been evaluated and updated on a regular basis. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 11 Staff were observed to be assisting residents in a sensitive and calm manner, and they were meeting residents needs in the manner stated in the care plans. Residents go out with staff regularly and attend a range of social and therapeutic activities. This is good evidence of how residents are well supported to take risks in their daily lives. Residents got up at different times during the morning, which helps to demonstrate how their choices and different preferences are respected. There are risk assessments in place to support residents to be able to maintain their own safety in the Home. The risk assessments support residents to be encouraged to live an independent and fulfilling life. The resident’s assessment record that was inspected had been reviewed and updated on a regular basis. This demonstrates that the Home review residents needs, and what they must do to make sure they minimise risks to them. 87 Church Road DS0000003341.V337397.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): 12,13,16,17.Quality in this outcome area is adequate. Residents take part in a variety of social and therapeutic activities suitable for their needs and can enjoy well-balanced diet. However mealtime service should be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A small group of residents went to Church during the inspection with the support of one member of staff. One resident said they liked to go to Church. This is a good example of the Home supporting residents to meet their spiritual needs. One resident kindly showed the inspector a photograph of them with the singer Daniel O’Donnell. The resident concerned had attended a recent concert of his, and had been able to meet him afterwards. They said they had liked the concert. This is a good example of residents being able to take part in the sort of activities that they enjoy. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 13 A couple of residents were seen humorously teasing one of the staff, who took this good-naturedly. This is good evidence of warm and friendly relationships between staff and residents. There are local facilities for residents to use in the area near the Home. Residents go out for coffee, as well as to nearby pubs, and other social venues thereby helping to ensure a varied and fulfilling life. Some residents go to the local church, and also to community based drop in mornings. The resident’s care records that were read include written information that confirmed they go to different community activities, including the shops, and different social activities. The menu record of residents’ meal choices was reviewed to see if residents are provided with a varied and well balanced diet. Residents are consulted about their preferred meal options for the following weeks meals. This is a good example of how residents are supported to make choices in their daily lives. There was evidence that residents choices were nutritionally well balanced, and varied. All of the residents said that the food at the Home was good. The lunchtime meal was roast chicken, stuffing, gravy, roast potatoes, and three cooked vegetables. The meal tasted adequate, it would have been improved for residents if there had been condiments, such as salt and pepper on the table. Residents had to wait at the table for twenty minutes before the meal was served to them, and were becoming restless which is understandable. 87 Church Road DS0000003341.V337397.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. Quality in this outcome area is good. Residents are being supported with their needs in the way preferred by them, and considerable effort has been made by the Home to try and make sure all residents’ needs are met; however one resident’s needs are not being fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the beginning of July 2007 based on discussion with the staff, and from information from South Glous Social Services department it is clear that the Home have not been able to fully meet one resident’s range of needs. The staffing levels have been increased to provide an additional member of staff for every shift to support the person on a one to one basis. This is needed when the person becomes angry in mood and cannot maintain their own safety, and also the safety of other residents is at risk. The action taken by the Home to ensure extra staff are provided is good evidence that the Home are trying to support all residents effectively. There was information seen in residents care records from the psychiatrist, who gives advice and support to residents with their particular needs. There are care reviews held in the Home involving residents, staff from the home and sometimes the psychiatrist, and social workers. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 15 All residents are registered with local GP Practices. This is evidence of how residents’ health needs are being met. There was information written in the care records about the preferred day-today routine of the residents and particular likes and dislikes. This helps ensure residents who use the service’ needs are met in the way that is preferred by them. There was also information in the daily records that staff monitor and observe the health of residents and call the doctor, if they were concerned about the person. There was information that showed that residents receive support and treatment as required from the specialist Psychiatrist. 87 Church Road DS0000003341.V337397.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. Residents are now protected from the risk of abuse or harm. However the changing needs and behaviours of one resident has until recently put residents at risk of harm. Residents’ views are listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints record book was reviewed to find out how effectively residents ’ complaints are dealt with. There had been no complaints recorded since before the last inspection. However resident’s views have been listened to. This is evident by the way the Home has recently responded when residents have been put at risk of harm or abuse by the action’s of another resident. This has been referred to in detail already in the report. There are procedures and guidance information on the topic of ‘ protection of vulnerable adults from abuse ’. This helps to protect vulnerable adults who live at the Home if staff has the necessary information to ensure their protection. The staff have attended recent training to help them better understand issues around the protection of vulnerable adults from abuse. This training is beneficial as it makes staff have a better understanding of what abuse is, and should protect residents as a result. The comments that have been written about the Home not reporting occurrences that could have been judged as regulation 37 occurrences are also applicable here. This is because the occurrences involve residents being put at risk of harm and physical abuse by the actions of another resident. 87 Church Road DS0000003341.V337397.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): 24,25,27,28,30.Quality in this outcome area is good. Residents’ live in a Home that is domestic in style and provides a suitable Environment to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 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. The Home was clean tidy and satisfactorily maintained in all areas that were viewed. There are two lounges, and an adequate sized dining area for the residents to use. This is beneficial as this helps ensure residents can maintain some privacy and personal space if they so wish. The kitchen is located opposite the dining room and is a domestic style. Residents are helped by staff to prepare drinks and snacks. This helps to 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 18 demonstrate residents live in a relaxed Home where they can be independent if they wish to be. There are toilets, and a shower and bathroom located close to bedrooms, which is convenient for residents. 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. One resident kindly showed the inspector their bedroom and some of their personal possessions. It was evident that the resident valued having their personal possessions around them in their room. 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 en-suite facilities. Bedrooms looked personalised with resident’s personal possessions, photographs, and artwork. There is furniture and fittings provided, including a wardrobe a comfortable chair a bedside cabinet and a chest of drawers in each room. There were also photographs, and pictures displayed in some rooms that helped to create a more personal feel to the room. There is a small laundry room with a washing machine and one tumble dryer. Staff help residents to wash their own clothes. This is another example of how they are supported to maintain independence in their daily living activities. 87 Church Road DS0000003341.V337397.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): 32,34,35,36.Quality in this outcome area is good. Residents are supported by a sufficient number of competent, qualified staff who are supported and supervised in their work. The Homes recruitment procedures could not be inspected at the inspection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 20 The staff duty record for shifts in July 2007 was looked at to check the number of staff on duty at any time to support residents. In the last six months four new members of staff have been recruited. Two of the new staff were on duty during the inspection and it was evident from comments made by residents how fond they have become of the new staff. Before July 2007 there were a minimum of three care staff on duty for a morning shift and three care staff on an afternoon shift. At night there was one staff member who works a waking night. However based on discussion with the staff, and from information from South Gloucestershire Social Services Department it is clear that the Home has not been able to fully meet one of the residents range of needs. In response to this the Home has increased the staffing levels to provide an additional member of staff for every shift to support the person on a one to one basis. This is needed when the person becomes angry in mood and cannot maintain their own safety, and also the safety of other residents is at risk. 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. The training records of three staff on duty were looked at to find out if staff attend relevant training. Staff need to attend regular training to help them gain a better understanding of residents needs, and in matters relevant to the effective running of the Home such as health and safety. The records demonstrated staff had attended training relevant to the needs of residents over the last six months. The staff consulted spoke positively about the training opportunities they take part in. This should help ensure residents needs continue to be met by the assistance of well-trained staff. The induction process was reviewed for three new staff members. Two of the staff are working through a detailed and informative induction programme. However one member of staff who had been working in the Home for five days had not yet been assisted to start a formal induction. This needs to be put in place for all staff so that they understand what their duties and responsibilities are in the Home, and also how they are to best support and assist residents. The staff meetings minutes record was looked at. These showed staff meetings take place on a regular basis and staff are consulted about a range of relevant matters related to the day-to-day running of the Home. The support staff on duty said that there was regular support and supervision provided by Mr Chard and the deputy manager. They said that they found the supervision sessions helpful. Records were not looked at as they were locked away and no one on duty had a key to unlock them. 87 Church Road DS0000003341.V337397.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): 37,39,41,42. Quality in this outcome area is adequate. Residents’ live in a Home that is adequately well run. However residents best interest have not always been safeguarded due to a lack of reporting of serious occurrences to the Commission for Social Care Inspection. Residents’ health and safety is partly protected. However residents’ health and safety concerning food safety practices is not sufficiently protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Chard is a qualified learning disabilities nurse. His career record shows he has a number of years of experience working with residents who have learning disabilities. He was on annual leave at the time of the inspection. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 22 Confidential records are kept in a secure cupboard by the office. This room is kept locked when not in use. This helps ensure residents confidential information is held securely. Generally records were satisfactorily maintained and in order. Other records have been referenced elsewhere in this report. However occurrences and situations that have an effect on the wellbeing of residents need to be reported promptly to us. 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 is a vital way for the Commission to monitor resident’s wellbeing in Care Homes. It is evident that from March to July of this year there were a number of incidents in the Home that should have been reported earlier to us. The monthly monitoring visits of the Home that must be carried out by a representative of The Trust 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. A detailed quality audit of the Home has been carried out by a registered manager of another Home in the area, to give a more independent perspective. A copy of the audit ‘tool’ was looked at. The views and outcomes for the residents are used as the main way of judging if the quality of care at the Home is good enough. This shows how the overall quality of the Home is being monitored on a regular basis, and the views of residents are central in this process. Staff do regular training in health and safety matters including first aid, and moving and handling practices. This should help protect residents’ health and safety if staff keep up to date in health and safety principles and practices. There was hand cleaning products and hand drying towels available at sinks in the toilets. This is so that residents, staff, and visitors can maintain good basic hygiene in the Home, and reduce cross infections risks. 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 23 The fire logbook record was checked and showed the required weekly and monthly tests of the fire alarms and the fire fighting equipment were being carried out and were up to date. There is a record of the monthly checks of the environment. These checks were up to date and showed that a member of staff audited the health and safety of the Home environment on a regular basis. The kitchen was tidy and organised when viewed. Up to date checks of kitchen fridges and freezers are maintained, to ensure they are operating within food safety guidance levels. Foods that food safety guidance advises are `high risk’ foods are temperature probed before serving to ensure the food has reached above minimum required temperature. However a new support worker who has only worked at the Home for five days and not undergone any form of induction was observed cooking the lunchtime meal. Staff who prepare and cook food for residents must be able to demonstrate that they can do this competently and safely. This is to protect the health and safety of residents. 87 Church Road DS0000003341.V337397.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 3 2 2 3 X 4 1 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 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 N/A 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X 1 2 X 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14. Requirement 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. All staff must complete a relevant induction program so that they understand what their duties and responsibilities, and how they support and assist residents. 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. All staff who prepare and cook food for residents must be able to demonstrate that they can do this competently and safely. This is to protect the health and safety of residents. Timescale for action 16/07/07 2. YA32 18.1(a) 16/08/07 3 YA41 37. 16/07/07 4 YA42 16.2(I). 15/07/07 87 Church Road DS0000003341.V337397.R01.S.doc Version 5.2 Page 26 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 YA2 Good Practice Recommendations Prospective residents should be given the chance to visit a Care Home before they move in to see what they think of it. 87 Church Road DS0000003341.V337397.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: 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.V337397.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!