Inspection on 24/06/05 for 87 Church Road

This inspection was carried out on 24th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

87 Church Road 14/05/08

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 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 Jackie Hargreaves Announced 24 June 2005 09:30 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 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 Stationary 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 D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 87 Church Road Address Frampton Cotterell South Glos BS36 2NE Telephone number Fax number Email 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 & Milestones Trust To be appointed Care Home for Younger Adults 8 Category(ies) of LD Learning disability for 8 registration, with number PD Physical disability for 8 of places LD(E) Learning dis - over 65 for 8 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 3 August 2004 Announced Brief Description of the Service: The Home is operated by Aspects and Milestones Trust, a non-profit making organisation. The building is an extended, large bungalow that can accommodate up to eight residents with learning disabilities and physical disabilities. This may include people 65 years and over. The home is currently accommodating eight residents who are over the age of 55 years. Two residents require the use of a wheelchair in the home. Three people use walking aids. The home is located in a semi-rural area approximately seven miles from Bristol City centre. There are local shops withing walking distance of the home. Transport is required to enable residents to access facilities further from the home as there are no local bus services within easy access. 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. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out in one day over 9 hours and focussed primarily on the statutory requirements made at the previous inspection and the care and support needs of the residents. The home was given 8 weeks notice of the inspection. The manager was absent from the home and the assistant manager was not on duty during this announced inspection. The inspector was therefore unable to fully assess some aspects relating to outstanding requirements, management of the home, policies and procedures, service development planning and staffing arrangements. The Commission received a preinspection questionnaire completed by the assistant manager. Some of this information has been incorporated into the report. Care staff were very helpful and cooperative despite being very busy providing for the needs of the residents. Records and procedures were looked at regarding admissions processes, care planning, staffing arrangements and aspects of health and safety. Care plans and life plans for three residents were scrutinised in detail and checked against care notes and personal safety assessments. Some aspects of care and support needs were discussed with three residents and staff to assess the outcomes of services provided to residents. Staff assisted the inspector to communicate with two residents. Six requirements from the previous inspection of the home have not been fully complied with. These have been carried forward and must now be addressed to avoid further action being taken by the CSCI. What the service does well: The home has a core of experienced and competent staff and those present on the day of the inspection were knowledgeable about the residents needs. The inspector observed good, friendly interactions between residents and staff. The inspector received positive comments from new residents about the home and the support they received from staff Residents are involved in staff recruitment. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 6 Each person has their own bedroom that they are encouraged to personalise. Residents health care needs are being addressed and staff provide support to enable residents to access community health services. What has improved since the last inspection? What they could do better: The major challenge for this service is to fully establish stable and effective management arrangements and planning for achieving the aims of the home and involving residents, better quality services, and high staff moral. The welfare of residents would be enhanced and good outcomes achieved from the services provided by ensuring less use of agency and bank staff and more consistency of support from sufficient numbers of regular, permanent staff who know and understand the residents and their needs and preferences. Requirements have been made to ensure that residents needs are properly assessed prior to entering the home and their admissions are fully evaluated with full consideration for their needs and views, the ability/suitability of the home to meet their needs and compatibility with other residents already living in the home. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 7 To ensure that staff know how to meet and plan for residents personal, social and healthcare needs and wishes their daily living plans must be kept up to date and fully reviewed on a regular basis. Equally, assessments on residents personal safety must be kept up to date and reviewed in context with each persons daily living/support plan. Two outstanding requirements from a previous inspection relating to staff training in the administration of rectal diazepam and policy and guidance on prevention of pressure sores must be addressed to meet the health needs of residents with severe epilepsy and mobility needs and to avoid further action being taken by the CSCI. Dining room space for residents using wheelchairs and walking aids must be sufficient to meet their mobility needs and ensure their safety. The service has been required to risk assess this area and supply a copy of the assessment to the Commission. The home has also been required to demonstrate that bedroom space for a resident using a wheelchair is sufficient and the bedroom is suitably equipped for the residents needs. The service should ensure that residents who wish to do so could lock their bedroom doors. Improvements to the ventilation in the conservatory, chairs and sofas must be planned to make them suitable and safe for residents. Fire safety procedures are generally good, however, the fire risk assessment must be reviewed to comply with fire regulations. Opportunities for residents to pursue a range of activities in the community that meet their needs and interests should be further developed in consultation with residents. 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. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5 Assessment and admission procedures were not of a good standard. EVIDENCE: Information about the service was held in the home. There was evidence that the new manager had updated the Statement of Purpose although copies of the Statement of Purpose and a residents guide to the home for residents to keep or for people to take away and read were not in evidence. Three new residents had recently entered the home during 2005. Information available relating to two residents was studied and their experiences of the admission processes discussed with them separately. No up to date needs assessments in preparation for admission and to enable the home to consider its suitability to meet their needs could be found for these residents although folders containing information and daily living plans had been transferred from their previous home within the Trust. Visits made to 87 Church Road by the residents were recorded although there was no evidence of written review meetings to evaluate the homes suitability for the residents taking into account their views of the home and those of residents already accommodated. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 10 Discussions with the residents confirmed that they had visited the home prior to moving in and were consulted about their views of the home. One resident said she visited the home for tea with a staff member from her previous home and had a weekend stay, to see if I liked it. Both residents confirmed staff from both homes supported them during their introductions and one resident commented that she had enough time to think about it. On further scrutiny of information held in one new residents folder the inspector was concerned that her last review meeting was dated 5 March 04 prior to moving to the home and terms and conditions of residency related to her previous address. The inspector later looked at information relating to the third resident who entered the home in March 05 and discussed this persons needs with a member of staff. This resident had also moved into the home from another home within the Trust. A pre-admission assessment and care plan could not be found for this person. Information on file confirmed that the resident had complex needs, and previous day care activities had stopped. Further discussions with a member of staff indicated that the home did not know enough about the person on admission to enable them to fully meet his personal and social needs. However, it was positively noted that this resident had input from healthcare professionals. All of the above evidence indicates that home had not followed satisfactory admissions procedures. The issues described must be addressed to ensure that these residents needs are properly assessed, they have made positive choices about the suitability of the home to meet their needs and wishes and these have been fully understood, agreed, and can be provided for. New placements must be properly evaluated with consideration for compatibility with other residents to fully establish whether or not each person is satisfied with the home and the changes, and if not, what action is required. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Although person centred planning with residents is being developed the current care/life planning system, including assessment of risks, does not ensure that that staff are provided with all of the information they need to fully meet residents needs. EVIDENCE: A member of staff explained that person centred planning with residents was being facilitated. This way of planning centres upon residents rights and concentrates planning on empowering residents to control what they want to happen in their daily lives and how they want to be helped. The inspector was advised that planning sessions had been held separately with three residents and the outcomes had still to be documented. Three files chosen at random holding current information and plans relating to the residents support needs and daily living preferences were studied in detail. Some aspects of these were discussed with staff and checked against care notes written by staff and assessments of residents personal safety needs. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 12 Essential life plans and care plans covered aspects of each persons healthcare, personal and social needs and demonstrated the residents contribution by incorporating their likes, dislikes, essential things and preferred routines. Overall, information in plans needed re-organising and updating and some specific aspects of the plans expanding such as communication needs and future aspirations to enable staff to work effectively with residents and to review progress towards independence or specific achievements. Alterations made to plans were not dated and some plans had not had a full review. Plans did not demonstrate that a residents changing mobility needs had increased and that behavioural incidents had been re-assessed and fully addressed. Without assistance from staff and reference to care documentation it was not possible to obtain a clear up to date picture of each person and their current daily support needs and wishes. Risk assessments relating to the personal safety of three residents were studied. The assessments related to risks associated with aspects of daily living and health needs such as epilepsy, bathing, food, mobility and going out of the home, and detailed the support required to manage or minimise risks. All had review dates and were signed. Personal safety risk assessments relating to one resident had been fully reviewed. Updates to other risk assessments had been noted. However, changes to a residents mobility needs, promotion of a persons independence while bathing and recent behavioural incidents recorded in care notes indicated that further updates were required prior to a full review of risk assessments to promote the safety of residents at all times. Risks relating to specific behaviours and guidelines for safe ways of working to support one resident through behavioural episodes were in place. However, evidence collated from this persons care documentation gave rise to concerns that behavioural incidents had increased and the causes of such incidents were linked to the residents compatibility with other residents and little opportunity for day activity due to reduced staff, which were not addressed in the risk assessment. This highlighted a need to ensure that full information is incorporated into risk assessments when decisions are made on how to manage risks and a need to ensure that assessments are in context with the persons daily living/support plan. This should ensure the right support is provided and good outcomes are achieved from the support provided to the residents. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 Only limited progress had been made in creating time and opportunities for staff and residents to plan for pursuing individual interests and using community leisure services more fully. EVIDENCE: At the homes previous inspection the inspector recommended that: • All key workers resume their involvement with service users and plan how to use the community more fully. • More staff time for residents to pursue their interests and for staff to talk with residents or to go out would be beneficial to residents. There was insufficient evidence at this inspection to demonstrate that these good practice recommendations had been fully implemented. Most residents attended activity/day centres on some days of the week. Two residents were asked about their other activities. Links with the local community were also discussed with a staff member and staff handover notes were looked at to see the range of opportunities provided for residents to engage in community and leisure activities. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 14 There was evidence that staff were creating opportunities for residents to undertake some routine domestic tasks in the home and to access their community through Church attendance, shopping at local shops, going to the local pub and out for lunch. Less evident was availability of staff time or effective use of resources to enable residents to engage in a variety of meaningful activities in the home and the community, specifically residents who had lived in the home for less than six months and those with more complex or behaviour related needs. One residents resource centre activities had stopped when they moved into the home and no alternatives were in place. One resident said they, were not going out as much since living in the home. Another resident whose care plan stated they liked dogs, going out as often as possible and loved trips out was going out infrequently and there were indications from care notes that this was a contributory factor in adverse behaviour changes along with limited support from regular rather than changing staff. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21 Overall, the health needs of residents are well met although limited progress had been made to ensure procedures and training are in place for the prevention of pressure sores and the administering of rectal diazepam. Funeral plans were being put in place. EVIDENCE: There was documented evidence of input by health professionals to meet residents healthcare needs and advise on their care such as physiotherapist and consultant psychiatrist. Medical notes demonstrated that residents were enabled to access NHS healthcare facilities and services such as chiropodist dentist, optician and GP. Rectal diazepam was prescribed for two residents with severe epilepsy. Currently only the assistant manager could administer this. During the previous inspection the inspector required all staff to be trained and proficient to administer rectal diazepam and residents agreement to this procedure sought. There was no evidence to demonstrate that this requirement had been addressed. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 16 At the previous inspection of the home the inspector required that a policy and follow through of assessments for all service users be done against the risk of pressure sores. The inspector found guidelines relating to a risk assessment having been undertaken specifically for one resident but no general policy on the topic. In this instance medical notes checked demonstrated that the guidelines had been followed and contact with the district nurse produced a satisfactory outcome for the resident. It was also required that training updates were undertaken for the prevention and care of skin breakdown. The inspector was not able to fully check compliance with this requirement owing to the absence of senior management. The home is therefore required to supply the CSCI with evidence of staff training in this respect. The previous inspection report required that staff were made aware of the need to take any pertinent opportunity to find out service users funeral plans. The inspector saw four residents files containing information on what they wanted to happen at the time of their death. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 There is a clear complaints procedure, which has been made user friendly for residents with reading difficulties. EVIDENCE: There was a complaints file with procedures in audio, plain language and pictures for people with reading difficulties. The procedures included the contact numbers of the Commission, Social Workers and Advocacy Groups. This is good practice. Two complaints had been recorded in the home since the previous inspection. These detailed the outcomes of the complaints and follow up action. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,28 The standard of the environment is generally good, however space must be sufficient to provide for residents with high mobility needs and to ensure a safe environment. Issues in the report relating to the conservatory and seating need to be addressed to ensure residents, safety and comfort. EVIDENCE: The previous inspection report noted that the home was no longer fully suitable for its stated purpose due to four permanent wheelchair users being accommodated in the home and the special requirements for these residents not being met. The Trust was also required to vary homes condition of registration that no residents, other than three wheelchair users accommodated in bedrooms below spatial standards at that time, may be accommodated in the home. A variation had not been sought, however, at this inspection only one person who used a wheelchair in the home was accommodated in a single room below this standard and a staff member told the inspector that this person could transfer independently from the wheelchair to the bed. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 19 There were two residents using wheelchairs to get around the home at the time of the inspection, however, three residents were using walking frames/aids. The space in the dining room was congested and the dining room was not easily accessible to all residents at all times. This point was raised at the previous inspection and the service was required to address this. The average living space for each resident should not be compromised because of residents admitted to home in wheelchairs or using walking aids who need more space. The service is required to supply written evidence to the Commission that demonstrates this, together with a copy of the homes updated Statement of Purpose detailing information about communal space and bedroom sizes. The bedroom with less than 12 sq metres of useable floor space accommodating a person in a wheelchair was not assessed on this occasion. The service is required to demonstrate in writing to the Commission that this room has sufficient space and is suitably equipped for the residents needs or supply an assessment relating to the accommodation undertaken by an occupational therapist. There was no offensive odour present and the home was light although ventilation in the conservatory was not good. A staff member commented that the conservatory could get unbearably hot and an air conditioning unit had been requested. Furniture and fittings were generally satisfactory although two chairs in the conservatory were difficult to get in and out of owing to collapsed springs and the settee was very hard and uncomfortable to sit on. Two bedrooms viewed were personalised and contained lots of photographs, personal possessions pictures, TV, DVD player and a range of toiletries. One resident said that they could not lock their bedroom door and wanted to be able to lock it. There was a sound monitor in one bedroom for safety reasons. This should be removed or replaced with a sensor alarm that does not intrude upon the resident. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 The current staffing situation is adversely affecting the standard and consistency of care and support provided to residents. EVIDENCE: Pre-inspection information supplied by the home showed an excessive use of Bank or Agency staff. Inconsistency of support provided to residents was also evident from a bank/agency staff request form that showed at least 22 bank or agency staff had worked in the home in the past month. Discussion with regular staff and an agency care worker and examination of duty rotas indicated that bank/agency staff were prepared by permanent staff for the work they undertook and were informed about residents needs. However, there had been instances when all except one staff member on shift had consisted of Bank and Agency staff. The home do not control the choice of these staff therefore one regular staff member may be working with two agency/bank who do not know the residents and are unfamiliar with their needs. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 21 There were minimums of three support workers on duty up to 5pm when there may be a minimum of two, which is insufficient to meet residents needs. The home was not fully staffed and the duty rota from 13 to 25 June 05 showed seven staff off work due to sickness or leave. Two staff were off sick and one member was on annual leave week beginning 26 June 05. Although staff morale appeared low at the time of the inspection individual staff members spoke positively about their work and were seen to be skilled, motivated and friendly in their interactions with residents. Staffing documentation for the newest staff members were complete except for copy references. Appropriate CRB checks had been carried out. A staff member advised the inspector that residents were involved in staff recruitment and a resident with high communication needs confirmed staff interviews and this. Up to date records relating to staff training, team development and a service development plan could not be found and will remain a focus for the next inspection. However, information provided for inspection purposes evidenced that staff training had been supported and several staff training sessions had taken place, mostly concerning the health and safety of the residents. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The service supports staff training to promote the health and safety of residents. However, residents have been unable to benefit from effective management practices owing to the instability and change in the leadership and management of the home over the past twelve months. EVIDENCE: Discussions with staff confirmed management changes involving temporary management at the home over the past twelve months had impeded clear direction and leadership throughout the home and management planning to achieve the aims of the home. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 23 On the day of this announced inspection, the recently appointed manager was absent from the home and the assistant manager was not on duty. The inspector was therefore unable to establish plans to address the future management strategies for the home for involving residents and to ensure residents benefit from a well managed home. The area manager was present for a short period of time to assist in looking at staff records and to briefly discuss the recent manager appointment. Development of quality assurance systems were not fully assessed at this inspection, however, questionnaires in pictorial format for completion by residents had been developed and there was evidence of responses to questionnaires sent to families. The Trusts quality standards audit had still to be completed. Standard 42 relating to safe working practices was not fully assessed at this inspection, however, information provided by the home for pre-inspection purposes evidenced that staff received training in health and safety issues and this was confirmed in discussions with staff. The homes fire logbook was scrutinised and showed that emergency lighting was checked on 5 May 05, fire equipment was checked and serviced in November 04, a fire drill was carried out on 11 April 05. A certificated fire safety course for six staff was held in February 05. The fire risk assessment needed to be updated. Pre-inspection information supplied by the home evidenced that the required policies and procedures relating to the health and safety of residents and staff were implemented and available in the home. 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 1 1 x 1 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x x 2 x x Standard No 11 12 13 14 15 16 17 x 2 2 x x x x Standard No 31 32 33 34 35 36 Score x 2 1 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 87 Church Road Score x 2 x 3 Standard No 37 38 39 40 41 42 43 Score x 1 x x x x x D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1)(2) Requirement Supply the CSCI with an updated copy of the homes Statement of Purpose. The updated document must detaill information about communal space and bedroom sizes. New residents must be provided with a residency agreement that demonstrates the conditions have been discussed and agreed by all parties. The service must ensure full up to date assessments that accurately reflect prospective residents needs and wishes are obtained prior to admission. Ensure that staff are knowledgeable about admissions policy and procedures. Admissions procedures must be followed to ensure that residents are appopriately placed. The service must ensure that residents care and daily living plans are up to date and accurately reflect each persons needs and wishes. Assessments on residents personal safety must be kept up to date and reviewed in context with the persons daily Timescale for action 30.09.05 2. 5 5(1) 30.09.05 3. 3,2 14 30.06.05 4. 5. 6. 3 3 6 14 14, 12(2)(3) 15(1)12(2 )(3) 30.10.05 30.06.05 30.09.05 7. 9 13(4) 30.09.05 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 26 living/support plan. 8. 19 13(4)(c) All staff to be trained and proficient to administer rectal diazepam and residents agreement to this procedure sought. A policy on the prevention of pressure sores to be put in place and accessible to staff.l Dining room space must be sufficient to meet the needs of residents and ensure their safety. The service is required to risk assess this area and supply a copy of the assessment to the Commission. The service is required to demonstrate in writing to the Commission that the bedroom with less than 12 sq m usable floor space accommodating a wheelchair user has sufficient space and is suitably equipped for the residents needs The service us required to supply the Commission with an action plan for ensuring that ventilation in the conservatory is satisfactory and suitable for the residents. Replace or repair two chairs in the conservatory that have collapsed springs and ensure that seating in the home is suitable for the needs of residents. The service must ensure that there are sufficient permanent staff in the home to provide consistency of care and support to residents Ensure there are sufficient numbers of suitably qualified, competent and experienced staff working in the home at all times to ensure the health and welfare 01.12.05 9. 10. 19 24,28 12(1)(a)( b) 23(2)(a)( g) 13(4)(a) 30.09.05 30.10.05 11. 26 23(2)(f) 30.10.05 12. 24 23(2)(p) 30.09.05 13. 24 16(1)23(2 ((i) 30.10.05 14. 15. 33,32,38 18(1) 30.09.05 16. 33,32 18(1) 30.09.05 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 27 of residents. 17. 18. 34 42 19 17(2) Staff employment references must be held in the home and available for inspection. Ensure the fire risk assessment is reviewed. 30.10.05 30.09.05 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. 2. Refer to Standard 13,12 3 Good Practice Recommendations The service should create more opportunities that enable residents to pursue interests and use their community leisure services more fully. New admissions should be properly evaluated with consideration for compatibility with other residents and to ensure new residents have made positive choices about the suitability of the home to meet their their needs and wishes. The service should ensure that residents who wish to do so can lock their bedroom doors. There was a sound monitor in one bedroom for safety reasons. This should be removed or replaced with a sensor alarm that does not intrude upon the resident. 3. 4. 25 25 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 87 Church Road D56 D05 S3341 87 Church Road V193323 240605 Stage 4.doc Version 1.30 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. 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!