Inspection on 29/01/07 for 87 Church Road

This inspection was carried out on 29th January 2007.

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 found no outstanding requirements from the previous inspection report, but 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 15/07/07

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 29th January 2007 09:20 87 Church Road DS0000003341.V327424.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.V327424.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.V327424.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.V327424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 30th August 2006 Date of last inspection 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 people 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, 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. The fees charged for staying at the service are £869.05 a week. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note due to their disabilities some residents have verbal communication difficulties. The inspector met five residents currently living at the Home. The manager, Mr Chard, and three 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 selection of records relating to the day-to-day running and management of the Home were inspected. A range of residents’ care records and care plans were also reviewed. The environment was seen throughout. There were a sample of pre inspection feedback forms sent to the Commission for Social Care Inspection area office, from residents, and relatives. This information has been used to help form the judgements in the report. The Home was operating within the required conditions of registration set down by The Commission. The conditions of registration set out the type of care and the needs of residents, as well as the numbers of residents who may stay at the Home. Sue Fuller a Commission Pharmacist Inspector inspected the standard for medication systems in the Home. What the service does well: What has improved since the last inspection? Care plans are now accurate and better reflect the care provided to residents. Residents care plans are now being reviewed and evaluated on a regular basis. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 6 Risk assessments are now being kept up to date and reviewed in context with the person’s care plan. The record of food served to residents now includes a record of lunchtime meal options. This helps demonstrate residents are provided with a varied nutritious diet. Residents are safer as wheelchairs now have footplate rests on them to protect residents’ health and safety. One resident’s needs and placement at the Home has been re-assessed. Protocols for some emergency treatments have been updated. Training has been provided to help staff to safely administer one medicine by specialised technique. The identified bedroom has a suitable two-way lock to open from the inside. 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.V327424.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.V327424.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): 2,3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being assessed and their needs are met. EVIDENCE: To find out how effectively residents are supported to meet their needs one residents’ assessment information was inspected. The assessment includes a detailed personal profile, about the person. This included the person’s life history and mental health history, as well as a record of the important people such as family and friends for the individual. There was also an informative plan of care for the resident setting out how to address the persons physical, mental, and social needs. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 9 The care plan aimed to promote the independence of the person in their daily lives. There was evidence written in the records that the resident had been consulted in the care planning process. The care plan had been evaluated and updated on a regular basis. This helps to demonstrate the resident’s changing needs are being kept under review. Staff were assisting residents in a warm and friendly manner. The staff were observed to be meeting residents’ needs in the manner stated in the care plan. However, based on the information in the care plan that was read, from observing and talking to staff the number of staff on duty needs to be reviewed. This is because one resident’s needs have changed recently and staff need to spend a lot longer with the person, and there needs to be two staff to help them. This has an obvious impact on the time that staff have to assist all residents with their care needs (see staffing section of the report). There was information in the care plan about potential risks the resident may face, and any risk behaviours. The plan of care set out what approaches staff should take to support the person to maintain their safety. There was information written in the resident’s record that showed staff were aiming to support the individual to maintain their independence in their daily living. Residents are consulted about their preferred meal options for the following days meals. This is a good example of how residents are supported to take a role in the day-to-day running of the Home. Residents get up at different times during the morning, which helps to demonstrate how their choices and different preferences are respected. Mr Chard said there are going to be regular residents meetings starting soon This will be a good opportunity for residents to be able to express their views about what matters to them. 87 Church Road DS0000003341.V327424.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and their care plans reflect how their needs are met. Residents are supported to make decisions and to take risks in their daily lives. EVIDENCE: 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 11 To find out how well residents are being supported to meet their needs one care plan was inspected. The care plan contained helpful information and included easy to follow instructions showing how best to assist the resident to meet their care needs. The care plan addressed the resident’s range of needs and set out how to respond and support the person if they were distressed or agitated. The manager had evaluated the plan of care to demonstrate the residents changing needs are being monitored and reviewed. To find out how residents are supported to maintain their safety in a range of activities one resident’s risk assessment record were reviewed. There was detailed information included about any potential risks the resident may face, and any risk behaviours they may exhibit. The risk assessment record set out the preferred approaches staff needed to follow to support the resident. There was information written in the resident’s records that showed staff support residents to maintain independence in their daily life both in and out of the Home. Staff take residents out on trips to the shops, to coffee shops, and out to lunch on a regular basis. Staff from the home support residents to attend a range of community based social and therapeutic activities. During the inspection two residents went out to day care activities, and one resident went out to meet an old friend and have a coffee with them. Residents receive support on a regular basis from day care staff to take part in a range of community activities. This helps to demonstrate how residents are supported to make decisions and maintain their own independence in their daily lives. 87 Church Road DS0000003341.V327424.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): 12,14,17.Quality in this outcome area is adequate. Residents are supported to take part in a range of appropriate activities. They are further supported to be a part of the community and to have personal relationships. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are supported to prepare and bake cakes for themselves and the other residents on a regular basis. This offers residents the opportunity to take part in a meaningful activity in the Home. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 13 There is information recorded in residents’ records that confirmed they attended a local drop in and activities centres. Two residents were out for the day at the social centre they go to on a regular basis. One resident is going on a short coach trip with the support of staff. This is a good opportunity for the resident concerned to have a holiday of their choices. A copy of the current residents food menu was reviewed. There was a range of dishes recorded as being available for each day. There was evidence seen that demonstrate residents likes and dislikes are now included when menus are planned. There was a varied choice of meal options available for the residents. Meal options included a range of traditional, nutritional meals. Three of the residents said that the food served was ` good ’. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are being supported with their needs in the way preferred by them, and their needs are met. Medicines administration record sheets and a check of medication indicated that medication is administered as prescribed. Action is needed to make sure that sufficient staff are trained to administer one medicine by specialised technique and that staff follow the home’s medication policies. EVIDENCE: 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 15 The resident’s care record that was reviewed includes a record of their physical health needs, and appointments (see also standard 6). This detailed the resident’s last optician, chiropody, dental and GP appointments that the resident has attended. This helps to demonstrate that residents’ health care needs are being met. Residents are being involved in care planning meetings with the staff and that are held to review their needs on a regular basis. One resident said they had attended a meeting with the staff last week. As already referred to in the report, there was written evidence in residents care records which showed the preferred day to day routine of the residents and their particular likes and dislikes. This helps to demonstrate how residents are being involved in the planning of their care. The plan of care also stated the preferred manner in which to assist the resident to meet their mental health and social needs. Staff were talking with the residents in a friendly manner and residents and staff have built up close relationships. The pharmacy provides medicines monthly using a blister pack monitored dosage system. At present none of the residents are able to look after their own medication. Two metal medicine cupboards are used to store medication. Storage must be organised so that the small box of medicines kept in a separate cupboard can be correctly stored in a medicine cupboard. At the time of this inspection there were a number of unwanted blister packs awaiting return to the pharmacy these should be returned to the pharmacy. Following a stay in hospital, medicines for one resident have changed and staff must ensure that all medicines kept for this person have the current dosage instructions to avoid mistakes in medicines administration. Staff record the receipt of medication on the medicines administration record sheet. Some medication received from another care home had not been recorded so it was not clear which medicines had been transferred to 87 Church Rd. Staff must obtain this information from the other care home, check that all the medicines can be accounted for and update their own records accordingly. Medicines administration record sheets and an audit of some medication indicated that medicines had been administered as prescribed and recorded. One resident sometimes refuses their medication and may take it later; if medicines are given significantly later than the prescribed time, staff should record the actual time of administration. This could mean that two doses are 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 16 taken quite close together. Guidance should be requested from the doctor to make sure that these medicines are always given safely. Guidance is available for staff about the administration of medicines prescribed, When required for each resident. Records sheets are kept for these medicines and these allow stock balances to be checked. These sheets have not been used consistently. It appeared that stock balances are not regularly checked, so discrepancies would not be easily seen. One medicine prescribed, When required for a resident had no record sheet making it difficult to check the balance. The stock of one medicine is checked at every shift change after a small number of tablets were lost. An extra recent supply needs to be added to the record so that they are included in the check. Protocols are available for residents needing treatment for epilepsy. The home manager has signed these; to protect residents’ health it is recommended that the doctor should also be asked to approve these. Training has been provided for staff so that they can safely administer rectal Diazepam for epilepsy. Further training is still needed to enable staff to safely another medicines, by specialised technique. 87 Church Road DS0000003341.V327424.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. Quality in this outcome area is poor. Residents are not being well supported to make complaints about the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints record book was looked at to see how effectively residents’ complaints are dealt with. There had been no complaints made since before the last inspection One resident said they talk to the staff if they have any, ‘worries’. The other residents who were asked did not know how to make a complaint. There is an easy to read complaints procedure for residents, and included in this is the contact details for the head of Aspects Trust as well as for the Commission for Social Care Inspection. However residents do not have their own copy of the procedure. This is necessary so that residents and their representatives have the information they need to be able to complain if they so wish. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ live in a Home that is domestic in style and provides an environment that is adequately suitable for them. EVIDENCE: 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 19 The Home is a purpose built bungalow designed building set in a quiet residential area near to the village of Frampton Cotterell. It is close to local shops and residents can access local amenities. There are three lounges for the residents to use, which is beneficial as this helps ensure residents can maintain their privacy and `personal space’ if they so wish. The residents looked settled and relaxed in their surroundings. Bedrooms have been personalised with personal possessions. Furniture and fittings are provided, including a wardrobe, comfortable chairs, 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 rooms. 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. There are toilets, and a shower or bathroom facilities located within close proximity of the bedrooms on each floor, which is convenient for residents use. The Home was satisfactorily clean tidy and adequately maintained in all areas that were viewed. However corridor walls and dining room walls look marked, worn and drab in appearance, and it would be beneficial to residents and staff if walls were repainted. The kitchen was located on the ground floor, leading onto the dining room. The kitchen was of a domestic style, and was satisfactorily clean and tidy. There is a small laundry room containing a washing machine and one tumble dryer to ensure residents’ clothes are washed and dried hygienically. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35,36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a sufficient number of competent staff. Residents also benefit from staff who are being supervised and supported in their work by the manager. However staff have not attended recent regular training and updating in matters relevant to residents needs. EVIDENCE: The recruitment procedures were not checked on this inspection. The Trust are in the process of moving all staff recruitment records back into the care Homes, however this has not yet taken place for staff at the Home. These records may be requested at the next inspection. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 21 There was information seen that demonstrated staff are booked to attend forthcoming training in food hygiene, first aid and fire safety. There was evidence that one of the care staff had attended training on matters relevant to resident’s needs and disabilities. However the majority of staff had not attended recent training and development opportunities in matters relevant to residents and their needs. The staff on duty did say they were hoping to attend forthcoming training days run by The Trust over the coming months. The staff duty record for January 2007 was reviewed to find out the number of staff on duty each day to support residents with their needs. There had been a small amount of sickness recorded and agency staff had covered the shortfall in staff. There are three staff on duty during the morning. There are two members of staff on duty in the afternoon. Mr Chard said that he will roster extra staff on duty on the afternoon shifts if residents are taking part in planned social and therapeutic activities. There is one member of staff who works a waking night shift. There is also an on call support system to support staff and residents out of hours and at weekends. However, based on the information in the care plans, from observing and talking to staff the number of staff on duty needs to be reviewed to ensure staff have sufficient time to meet all residents needs. This is because one resident’s physical care needs have recently changed significantly, and they need much greater assistance from staff. The staff observed during the inspection conveyed they were able to communicate and support residents in a sensitive manner. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a satisfactorily run Home. Residents’ and staff health and safety is being protected. The Homes records keeping generally protect residents’ rights and best interest. 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. He is not yet registered with the Commission for Social Care Inspection as the manager, although an application pack is in the process of being completed and sent to the Commission for Social Care Inspection. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 23 The Home ensures residents’ records are kept in a locked cabinet in the office when not in use. The care records, and the records that were seen relating to the running of the Home were satisfactorily written, legible, up to date, and reasonably maintained. This helps to demonstrate residents’ confidentiality is protected, and that legal records required for the effective running of the Home are being kept in order. 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. There are allocated staff who oversee health and safety matters in the Home. Staff are provided with 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 is a first aid box that is kept in the office, and this room is locked when not in use. However currently there is no first aid box in the kitchen where the majority of accidents in homes take place. There are hand cleaning products and hand drying towels available at sinks in the toilets. This helps residents, staff, and visitors to maintain good basic hygiene in the Home, and reduce cross infection risks. 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. 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 N/A 35 1 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 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X 3 3 X 87 Church Road DS0000003341.V327424.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA22 YA33 YA35 Regulation 22. (5) 18.1(a) 18.1(c) Requirement Timescale for action 07/02/07 4 YA20 13.2 Residents must have their own copy of the complaints procedure. Staffing levels must be reviewed 28/02/07 and adjusted to ensure all residents’ needs are met. Staff must undertake regular 29/04/07 training and development opportunities to maintain a good understanding of residents’ range of needs. The registered person shall make 29/03/07 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home: - Staff must have training by a suitably qualified person to administer one medicine by specialised technique, to meet one resident’s needs. - records must be kept of all medicines received into the home. 87 Church Road DS0000003341.V327424.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. 2. 3 Refer to Standard YA42 YA24 YA20 Good Practice Recommendations There should be a first aid box in the kitchen The corridor walls and dining room walls should be repainted. Written evidence should be available that the residents’ doctor has approved the protocols for emergency treatment of epilepsy. Guidance should be requested from the doctor about late administration of medicines, which have been refused by a resident. Record sheets for medicines prescribed, When required should be used consistently and checked regularly to make sure that the use of these medicines can be monitored. 87 Church Road DS0000003341.V327424.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.V327424.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!