Inspection on 30/08/06 for 87 Church Road

This inspection was carried out on 30th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 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 29/01/07

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 30th August 2006 09:30 87 Church Road DS0000003341.V309550.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.V309550.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.V309550.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 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.V309550.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. 25th November 2005 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.V309550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four of the residents were consulted during the inspection to find out their views of the service. Time was also spent sitting in the lounge with residents, observing staff carrying out their duties. Three care assistants were consulted about training they have undertaken, and how they assist and support residents. The area manager was also consulted during the inspection. A range of records relating to the day-to-day running and management of the Home were inspected. The whole of the environment was viewed both internally and externally. The Home was operating within the required conditions of registration, which are set down by the Commission for Social Care Inspection. 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. What the service does well: What has improved since the last inspection? What they could do better: The Home must recruit a permanent manager who is put forward for registration with the Commission for Social Care Inspection. An action plan is needed to address the lack of permanent manager until a manager is recruited. To protect residents there must be sufficient staff trained to administer `give when required’, rectal diazepam on duty at all times. There should also be protocols to guide staff to administer all medication that is given, `when required.’ 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 6 One resident’s needs and placement at the Home must be re-assessed as matter of priority as the person’s needs and behaviours are having a significant impact on the quality of daily living of other residents. Also based on the findings at the inspection the Home is not currently fully meeting the person’s needs. The identified resident must be transferred in their wheelchair safely. Staff must not `tip’ the wheelchair up when moving the resident. Residents’ care plans must be accurate and reflect the care that is being provided to them. Care plans must also be reviewed and evaluated on a more regular basis to demonstrate how residents’ changing needs are being monitored. Residents’ risk assessments of their personal safety must be kept up to date and reviewed on a regular basis. Wheelchairs must have footplate rests unless there are clearly identified reasons not to have them. The reasons not to have footplates must be documented in residents’ care plans and based on residents’ preferences. All high-risk foods should be temperature probed to ensure they have been cooked to above the safe minimum guidance temperature. The record of food served to residents must be more detailed, and include a record of what lunchtime meal options are for residents. The dining room chairs must be replaced with more suitable, safer chairs. Currently residents have been using `hospital’ style chairs with wheels on that closely resemble commodes and do not reflect the care home setting or uphold the dignity of residents. Also there was a metal part of one chair that was sticking prominently from the side of it and could cause an injury. The Home must be able to demonstrate the use of `baby’ sound monitors in residents bedrooms is done to maintain residents safety, and is part of their agreed plan of care, and residents have consented to the use of the monitors. Action must be taken so that the bedroom door with a lock that cannot be opened from the inside is two way lockable. 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 DS0000003341.V309550.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.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents’ needs are only partly assessed and residents’ needs are not being fully met. EVIDENCE: To find out how residents’ needs are assessed, two residents’ assessment records were looked at in detail. There was a range of assessment information in the first resident’s records selected. There was some information about how to respond to the resident if they got extremely verbally angry or physically aggressive. However based on the four regulation 37 reports, about incidents concerning the residents angry behaviour towards other residents sent to the Commission for Social Care Inspection since the last inspection in November 2006, on the inspectors observations, and from reading the residents assessment records and care plan it is evident the person’s placement at the Home must be re assessed as matter of priority. The resident’s needs and behaviours are having a significant impact on the quality of daily living of other residents. The inspector observed three residents express annoyance towards the behaviours of the resident concerned. Also based on the findings at the inspection the Home is not currently fully meeting the person’s needs. Two examples of this are firstly, the need to take the resident’s blood pressure regularly and secondly the need to 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 9 weigh the person regularly. These needs have not been met, regularly, by the staff. In discussion with staff, it was also evident that staff are responding to the resident’s extreme anger and aggressive behaviours in very different ways. Some staff had been advised to transfer the resident when they are very angry in mood by tipping the wheelchair up when moving the resident. This must not be repeated, and demonstrates a lack of suitable guidance for staff, and is potentially very dangerous. The second resident’s care plan included an assessment of the physical, mental health and social needs of the person. Included in this assessment were the likes and dislikes of the resident, and their preferred choice of social activities. However, this resident’s assessment record said they need to be weighed regularly and this was also not being carried out. Also the assessment records had not been reviewed and evaluated on a regular basis. This is required to demonstrate how the Home is monitoring residents’ changing needs. The three staff who were consulted conveyed in discussion and through observations that they had a good understanding of the needs of the residents. The staff who consisted of two agency staff who work in the Home very regularly, and one `bank’ worker, all conveyed that they were kind and caring and working hard to try and meet residents’ needs. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents’ assessed and changing needs are not always being reflected in their care plans. Also risk assessment records are not up to date or accurate. The use of sound monitors to monitor residents’ needs must also be reviewed. EVIDENCE: To find out how effectively residents are being supported to meet their needs two care plans were inspected. The care plans contained a range of information, and included psychological plans of care for residents. However, as already referred to in the report, when staff were asked how they support one resident with their needs when they are very agitated and angry, staff said they had been advised to transfer the resident in their wheelchair by tipping it up and taking the resident to their room away from other residents. This is potentially abusive, and was not how the residents care plan stated their needs should be met. The resident’s care plan needs to be accurate and reflect the care that is being provided to residents. 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 11 The second resident’s care plans included information showing how to support, and communicate with the resident and how to assist them with their psychological and physical care needs. However the care plans that were seen had not been evaluated and up dated on a regular basis. This is required to demonstrate staff monitor residents’ changing needs. Also it was observed that the Home are using `baby’ sound monitors in two bedrooms to monitor residents at night. The Home must be able to demonstrate this is done to maintain residents’ safety, and is part of their plan of care, and they have consented to the use of the monitors. Individual files contained relevant letters and assessments from a psychologist and a psychiatrist who will see residents when required on an outpatient basis at a nearby hospital. There was a physical health care needs record in resident’s records which recorded when the person had last had routine optician, chiropody and dental appointments. However Ms Jolly said that these records were not being kept up to date by the staff and she was in the process of addressing this matter as a priority. The staff also keep daily progress records, which they write to demonstrate they are monitoring residents’ wellbeing, and theses records were being kept up to date. Each resident has a risk assessment record in place to try and guide and support staff in maintaining the residents safety in a range of daily living and therapeutic activities. However both residents risk assessment records contained information that was not clear, and was not sufficiently detailed. For example one resident’s risk assessment, for if they were choking on their food, referred to the need to `pat’ the person on the back to dislodge the food, but there was no further guidance for staff if this action was not successful. There needs to be up to date risk assessments in place to help to protect the health and safety of residents and staff. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,17 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are supported to take part in social and therapeutic activities. Residents are also provided with a healthy diet although there is a lack of evidence to demonstrate what choices residents are offered at lunchtimes. EVIDENCE: 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 13 A copy of the current residents’ menu was reviewed to find out if residents are being offered a well balanced and varied diet. There was a range of dishes recorded as being available for each day. The staff reported that resident choose their preferred meal options. However there were no written records, other than `clients choice’ about what meal choices residents have at lunchtime. Staff said that residents do make choices, and at lunchtime there was a choice of sandwiches for residents. However, the menus should include this information to demonstrate that a varied choice of meal options is available. Evening meal options included a range of traditional, nutritional meals. The lunchtime meal options included assorted sandwiches. Three residents said that the food at the Home was `very good.’ One resident’s birthday coincided with the day of the Inspection. The staff had clearly worked hard to make the day enjoyable for the resident and had bought presents and arranged a birthday cake for them, and they clearly very much appreciated this. There was also information written in the two residents’ records that showed residents go out into the community for social and therapeutic trips. One resident goes to a local drop-in group, supported by day care staff during the week. The staff also said that they take residents to the nearby shopping centre on a regular basis, and out for a coffee or lunch. One resident went out with staff to the nearby shops during the inspection. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There is no evidence to demonstrate residents are being supported with their needs in the way preferred by them, and residents’ needs are not being fully met. Also while residents’ medication is stored and disposed of safely, there is lack of evidence that resident’s medication is always administered safely. EVIDENCE: To find out how residents are being supported by staff to meet their needs two care plans were inspected. The care plans included some information showing how to support, and communicate with the residents and how to assist them with their needs. However staff when consulted during the inspection staff had very different approaches when responding to residents’ needs that were not identified in the care plans. Also the care plans that were seen had not been reviewed or evaluated on a regular basis. This is required to demonstrate how resident’s needs are being monitored evaluated and updated. There was a record maintained in the two residents care records seen of the physical health needs, and appointments (see also standard 6) however the records had not been kept up to date. This is required to demonstrate when 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 15 residents’ optician, chiropody, dental and GP appointments have taken place. This helps to demonstrate that residents’ health care needs are being met. It was also observed that wheelchairs did not have footplate rests on them. There was no evidence in residents’ care records that gave clearly identified reasons why residents did not have footrests. The reasons for this need to be documented in care plans and based on resident’s preferences and as part of their agreed plan of care. The procedures for the administration, storage and disposal of medication were reviewed to check if there are safe systems in place for the handling administration and storage of medication. The medication administration charts of three residents were looked at in detail. There was a photograph of the resident kept with their record, to ensure medication is dispensed to the correct person. The medication administration charts were legible, up to date, and contained the signature of the dispensing member of staff. The reasons for any omissions had also been written on the charts. Up to date records were also kept of medication being received into the Home, and medication sent back to the pharmacy, showing there are safe systems in place to monitor how much medication is held. However there are two residents who need to be administered `give when required’ rectal diazepam and there are currently no staff working at the Home who are trained to administer this medication. This needs to be addressed as a priority to ensure the health and safety of the residents. Also for residents who are prescribed other medications that are only needed `when required’ there are no protocols to guide staff as to when this medication should be given. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this inspection they will be inspected at the next key inspection of the service in 2006. EVIDENCE: 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a Home that is generally suitable for their needs and lifestyles and promotes their independence. However the dining room chairs need to be replaced, and one bedroom door lock needs to be safe for the resident occupying the room. EVIDENCE: 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 18 87 Church Road Care Home is an older property set in a quiet residential area. The Home is close to nearby shops so that residents can access local amenities. There are two lounges and a dining room for residents to use. However the dining room chairs need to be replaced with more suitable domestic style chairs as currently residents have been using `hospital’ style chairs with wheels on which closely resemble commodes in appearance and do not reflect the care home setting. Also there was a metal part of one chair that was sticking prominently from the side of it and could cause a resident an injury. The residents looked reasonably relaxed and comfortable in their surroundings. Residents’ rooms were personalised with personal possessions. There was 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 rooms that helped to create a more ‘personal’ feel to the rooms. One resident showed the inspector their bedroom and said they ` liked it’. The bedrooms were satisfactorily clean and tidy. The standard of the decoration and the quality of the fixtures and fittings was satisfactory. Bedrooms do not have en-suite facilities but they do have a sink in them. The majority of bedrooms have two way locking device to protect residents’ privacy. However, one resident’s bedroom has a lock that cannot be opened from the inside. This is required for health and safety reasons, as well as to uphold the resident’s rights. The kitchen is located opposite the dining room, and is of a domestic design and was satisfactorily clean, tidy and organised. This helps to demonstrate food is stored in a safe environment. There are toilets, and bath facilities located within close proximity of the rooms on each floor, which is convenient for residents’ use. There is a small laundry room. It contains two washing machines and one tumble dryer. This help to minimise the risk of cross infection in the Home. Staff also demonstrated a good understanding of procedures to minimise the risks of cross infection in the Home, and were observed wearing gloves and plastic aprons when necessary. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,36 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents are supported with their needs by a sufficient number of staff. However there is a lack of permanent staff employed at the Home and a lack of staff supervision and support. EVIDENCE: 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 20 The care staff on duty discussed training that they had attended to enable them to fulfil their duties working at the Home. The staff had both attended some relevant courses within the last twelve months. The staff also said they had attended health and safety training that related to needs of the residents in their care. The staff duty record for August 2006 was reviewed to check how many staff should be on duty at any time to support residents with their needs. There has been a significant amount of sickness recorded and regular agency staff or bank care staff had covered the shortfall in staff. The three staff on duty as already stated were not permanent members of the staff team, although all three staff have recently been working in the Home on a very regular basis. The three staff had clearly worked hard to build up good relationships with residents in the absence of at least four full time staff. There are three staff on duty during core hours, to provide residents with support during the day. There is one member of staff on duty at night that works a waking night duty in the Home. There is also an on call support system to support staff and residents out of hours and at weekends. However based on the overall findings of the inspection, the lack of permanent staff as well as a permanent manager is having a negative impact on the staffs’ ability to fully meet residents’ needs. The supervision records of staff were not looked at on this occasion. However Ms Jolly said that staff supervision in the Home was not up to date and had fallen behind, and she was in the process of taking action to address this failing. This practice of staff supervision is necessary as it benefits residents if staff feels well supported to be able to provide the support, care, and understanding of the residents and their needs. 87 Church Road DS0000003341.V309550.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,41,42, Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The lack of management in the Home is having a negative impact on residents’ daily lives. Also residents and staff health and safety is partly protected. EVIDENCE: The Home ensures residents’ records are kept securely in the office. The residents care records, and the records that were seen relating to the running of the Home were satisfactorily written, legible, up to date, and generally well maintained. This helps to demonstrate residents confidentiality is being protected, and also that legal records required for the effective running of the Home are being kept in order. There is currently no permanent manager working at the Home. This is having a significant impact on the overall quality of service and care the residents are receiving, as well as on the overall needs and development of the staff team. To address this matter in the short term Ms Sheila Jolly an area manager with 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 22 Aspects and Milestones Trust has very recently started working at the Home on a regular basis until the recruitment of a permanent registered manager. 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. The kitchen was inspected to see if food is stored and prepared in a safe area. The kitchen was being kept satisfactorily tidy and organised when seen. There are checks of kitchen fridges and freezers, to ensure they are operating within food safety guidance levels. However currently high risk foods are not being temperature probed on a regular basis to ensure they have been cooked to above the safe minimum guidance temperature. The staff are being provided with regular training in health and safety matters including first aid, food hygiene training and moving and handling practices. The three staff on duty had all undertaken recent food hygiene up date training and first aid training. This benefits residents as it protects their health and safety if staff are knowledgeable and well trained in these health and safety principles and practices. 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 1 3 1 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 1 X 1 X X X 3 3 X 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA17 Regulation Requirement Timescale for action 31/08/06 2 YA3 3 4 5. YA6 YA6 YA9 5. YA20 6 YA37 Schedule4.13 The record of food served to residents must include a record of lunchtime meal options. 13(6) Wheelchairs must have footplate rests unless there are clearly identified reasons not which are documented and based on residents preferences. 15. (2), (a) Residents care plans must be reviewed and evaluated on a regular basis. 15 Care plans must be accurate and reflect the care that is being provided to residents. 13. (4) Risk assessments must be kept up to date and reviewed in context with the person’s daily living/support plan. Outstanding requirement from the last inspection. 13(2) There must be sufficient staff trained to administer `give as required’ rectal diazepam on duty at all times. 8 An action plan must be put in place to address lack of permanent manager until a manager is recruited. DS0000003341.V309550.R01.S.doc 31/08/06 01/10/06 01/10/06 01/10/06 01/11/06 01/10/06 87 Church Road Version 5.2 Page 25 7 YA6 12. (4)(a) 8 YA3 14(2) 9 10 11 YA6 YA24 YA26 12.4(a) 23. (2)(e),(i) 23.(2)(b) The monitors must be only used if based on residents needs, and consent has been obtained. One resident’s needs and placement at the Home must be re assessed as matter of priority. The identified resident must be transferred in their wheelchair safely. The dining room chairs must be replaced. The identified resident’s bedroom must have a suitable two-way lock that can be opened from the inside. 01/10/06 01/10/06 30/08/06 01/11/06 01/10/06 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 YA20 YA42 Good Practice Recommendations There should also be protocols to guide staff to administer all medication that is given `when required’ All high-risk foods should be temperature probed to ensure they have been cooked to above the safe minimum guidance temperature. 87 Church Road DS0000003341.V309550.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 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. 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