Inspection on 25/06/07 for Ashclyst

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ashclyst 15/12/08

Ashclyst 23/06/08

Ashclyst 03/05/06

Ashclyst 16/11/05

Ashclyst 04/05/05

Ashclyst 25/10/04

Ashclyst 22/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ashclyst 23 Park Lane Winterbourne South Glos BS36 1AT Lead Inspector Melanie Edwards Key Unannounced Inspection 25th June 2007 09:20 Ashclyst DS0000003390.V336895.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 Ashclyst DS0000003390.V336895.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. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashclyst Address 23 Park Lane Winterbourne South Glos BS36 1AT 01454 250946 0117 970 9301 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Ian John Knowles Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 4 residents aged 19 - 64 years Date of last inspection 3rd May 2006 Brief Description of the Service: Ashclyst is situated in South Gloucestershire in a somewhat remote, almost rural position on the outskirts of Bristol. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care to four residents with a learning disability aged between 19-65 years of age. It is a modern 4 bedroom detached bungalow. Accommodation is on two floors. Residents have access to two bathrooms. The communal areas consist of a lounge and an open planned dining room and kitchen. Residents have access to a minibus in addition to public transport to enable them to access the local community. The home is managed by Mr Knowles. The fees at the time of publication of this report were £1250. Presently there is no Email address for the home. Ashclyst DS0000003390.V336895.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 it is hard for residents to express their views verbally. Two of the three residents were at the Home during the inspection. Time was spent talking to three members of staff on duty about their roles, responsibilities and training and development needs. Staff were observed assisting residents with their range of care needs. A sample of records that relate to the day-to-day running of the Home, as well as care records were inspected. The Home was viewed throughout. The Home was operating within the required conditions of registration, which we impose. The conditions of registration set out the type of care and the needs of persons as well as the numbers of persons who may stay at the Home. What the service does well: What has improved since the last inspection? What they could do better: Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 6 The service users guide must be up to date. Specifically there needs to be up to date information explaining that the Care Standards Act 2000, is the legislation Care Homes follow. The guide must also explain that it is the Commission for Social Care Inspection who regulate Care Homes. The current service user guide is not up to date. It refers to the old Inspection Unit disbanded in 2001, and to the old legislation. This information is important for residents, their representatives, and staff. One resident’s assessment record must be more detailed. Specifically the reasons why a `baby monitor ’ is used by staff to monitor the person when they are in their room need to be satisfactorily explained. The assessment must demonstrate how this helps to maintain the persons safety when they are physically unwell. One member of staff has not attended recent fire safety update training. This training is necessary so that all staff know what to do in the event of a fire in the Home . The Home must be kept satisfactorily clean. Specifically action must be taken to reduce the amount of dust on surfaces in bedrooms. All staff should attend regular training on the subject of the `protection of vulnerable adults ’. This is to help increase staff understanding and to help protect residents from harm and abuse. 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. Ashclyst DS0000003390.V336895.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 Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2. Quality in this outcome area is adequate. Residents have their needs met and generally they have their needs assessed. Residents are given most of the information that they need to help them make informed choices about the Home. However some information in the service users guide is not up to date. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how residents can get the information they need about the Home a copy of the service users guide was read. The service users guide has been written in a format that is easy to read. The guide includes information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet peoples needs is included. The complaints procedure is in the document for residents to know how to complain. There are pictures of the Home, and community to help inform the reader about the service. However the guide is not up to date, specifically the guide does not explain that it is the Commission for Social Care Inspection who regulates Care Homes. The service users guide refers to the old Inspection Unit disbanded in 2001, and to old legislation. This information is important for residents, and their representatives, and for staff so that they know whom to contact if have any concerns about the Home. The three staff consulted conveyed in discussion and through observations of them supporting residents, that they had a good understanding of their needs. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 9 Staff were also observed talking to residents in a warm manner. One of the residents spent considerable time sitting next to staff in the office, they looked very relaxed and comfortable in their company. This helps to demonstrate that residents are well supported and feel very comfortable with the staff. To find out how well residents needs are met one care plan was read. There was helpful and detailed information written that clearly showed how to assist the resident with their different needs. This is referred in detail in the next section of the report. To find out how effectively residents’ needs are assessed one assessment record was read. An informative assessment had been written about the residents’ physical, mental health and social needs. In the assessment was information about the likes and dislikes of the person, and their preferred choice of social and therapeutic activities. The assessment had been written in a person centred style. This helps staff to see the person as a unique individual with their own wishes and values. However the resident’s assessment record did not include an assessment of the reasons why a `baby monitor ’ is used to listen in on the person in their bedroom. Nor was there any form of assessment in place that demonstrated how this equipment helps to maintain the persons safety when they are physically unwell. There was evidence written in the assessment record showing it had been regularly evaluated and updated. This helps to demonstrate resident’s needs are monitored and reviewed. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. Residents are well supported to take part in a range of appropriate activities. They are also supported to be a part of the community and to take risk as part of their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how effectively residents are being helped by staff to meet their needs one care plan was read in detail. There was a personal profile completed about the resident. This included their personal history and information about their physical and mental health history, as well as important people in the residents lives. There was also an informative plan of care to address the person’s physical, mental, and social, needs. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 11 The care plan aimed to promote the independence of the person in their daily life. There was evidence written in the record that staff had included the wishes and opinions of the person when planning their care. There was also evidence that the care plan had been evaluated and updated on a regular basis. Staff were observed to be assisting residents in a calm manner. They were meeting one of the resident’s needs in the manner stated in the care plan that was read. Residents go out with staff on a regular basis and attend a range of social and therapeutic activities such going to the pub, to coffee shops, the cinema, and the supermarket and for drives to the Cotswolds . Residents were also observed going out with the support of staff on a one to one basis throughout the day to venues in the community. This is good evidence of how residents are well supported to take risks in their daily lives. There was detailed information included in care plan that was read that set out the potential risks the person may face, and any risks from particular activities that they take part in. The plan of care set out the preferred approaches staff should take to support the person to take risks in their daily life. There was also information written in the resident’s records that show staff were aiming to support them to maintain their independence in their daily living. Residents were observed having unrestricted access to the Home and the grounds. This helps demonstrates their freedom of movement is not restricted. Residents got up at different times during the morning, which helps to demonstrate how their choices and different preferences are respected. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,17. Quality in this outcome area is good. Residents are well 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. Residents are provided with a well balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 13 One aim of the Home as written in the service users guide is to support residents to be able to access community facilities as independently as possible. All residents have been for at least one holiday this year with the support of staff. This is a very good example of residents being well supported by staff to take a holiday. There was information recorded in resident’s files that confirmed residents regularly attended local activities and one resident is provided with day care support. Two residents were seen leaving the Home to attend community social and therapeutic day care activities. The current menu record was reviewed to check if residents are offered a varied and well balanced diet. There was a range of dishes recorded as being available for each day. There was evidence seen that demonstrate residents likes and dislikes are included when menus are planned. There was a varied choice of meal options available. Meal options included a range of traditional, nutritional meals. Since the last inspection the staff explained that they have reviewed and adjusted the menu to include more healthy meal and snack options for residents if they so wish. This was evident from the residents’ menu that was seen. Ashclyst DS0000003390.V336895.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 good. Residents are being supported with their needs in the way preferred by them, and their needs are being met. Medication is being stored and administered safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was information in the daily records showing how staff monitor and observe the health of residents. Staff said that they call the doctor if they have concerns about the person. One resident has recently been physically unwell and the staff team reported that the GPs. had provided very good medical support for the person. There was information that showed residents are supported as required by the Psychiatrist and their team. Residents go to a local dentist with the support of a member of staff. There was information recorded in care records confirming residents attend regular appointments at the doctor and the dentist. This is good evidence to demonstrate that residents are well supported to ensure their health needs are met. As has been written in standard 6 of the report, there was information in the care records that about the preferred day-to-day routine of residents and their particular likes and dislikes. This information helps ensure residents’ needs are Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 15 met in the way that is preferred by them. Staff who were consulted were familiar with the information in care plans, and how best to support residents with their care needs. The procedures and systems in place for administration, storage and disposal of medication were checked to monitor if the systems are safe. The medication administration charts of two residents were inspected. There was a photograph of the person maintained with each record. This should ensure medication is administered correctly to the person named on the chart. The administration charts were up to date, legible and in good order. The staff had signed for medication administrated, or recorded the reasons for any omissions.All staff administering medication complete regular training to enable them to do this safely. There are guidelines in care plans to advice the staff of the preferred way that residents like to take their medication. This will guide staff and ensure medication is administered in the way residents prefer. The stock of medication held in the Home was satisfactorily organised. Medication that was no longer required was being returned to the pharmacist. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. Residents are well supported to make complaints about the service. There are systems in place to protect residents from abuse. However residents would be better protected if all staff attend training on the subject of `protection of vulnerable adults ’. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints record book was looked at to find out how effectively resident’s complaints are responded to. There had been no complaints made since the last inspection. However the senior support worker talked about two recent examples of advocating on behalf of residents to make complaints for them. One complaint had related to below standard accommodation for residents on a recent holiday .The second complaint had involved supporting one resident to receive a higher rate of Disability Living Allowance. These are good examples of resident’s complaints being taken very seriously by the Home. All of the staff consulted demonstrated how to support residents if they judged that the person concerned wanted to make a complaint. There are procedures and guidance information on the topic of ‘the protection of vulnerable adults from abuse’. This helps to protect vulnerable adults who live at the Home, if staff can access the necessary information to ensure their protection. However the majority of the staff team have not attended recent update training on the subject of the ‘protection of vulnerable adults’. Updating this training is necessary to help to increase staff understanding, and to thereby further protect the residents from the risk of harm and abuse. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,29,30.Quality in this outcome area is adequate. Residents’ live in a Home that is domestic in style and provides an adequate comfortable environment. However cleanliness in the Home needs to be addressed as a priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashcylst is a converted private home close to private houses, a short distance from the villages of Winterbourne and Frampton Cottrell and near to bus stops. This helps ensure residents can be a part of the community. The Home has its own garden that looked to be satisfactorily maintained. There are patio seats and a spacious area where residents can sit and walk safely. The building is mostly wheelchair accessible. The Home is a two-storey building, and residents have access to each floor. However there is a steep step going from the dining room to the lounge. Residents with reduced mobility would need adaptations to be put in to help them down the step. There are adaptations in place to assist residents and visitors with disabilities in other parts of the Home. There are also bedrooms on the ground floor and the first floor, for residents who cannot manage the stairs. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 18 Residents looked relaxed and comfortable in their environment. One resident was sitting in the kitchen at the kitchen table spending time with staff, and they looked comfortable there. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with towels and soap to help minimize risk from cross infection. However the Home was not satisfactorily clean in all parts of it. Specifically there was dust on the surfaces in all of the bedrooms. At the last inspection a requirement had been sent for a refurbishment plan to be sent to the Commission setting out timescales for a range of repair work to be carried out both inside the Home and externally. This requirement has been partly met. However the kitchen units are old and only just adequate for use Serious consideration must be given to the kitchen being fully refurbished. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36. Quality in this outcome area is good. Resident are cared for by a sufficient number of competent, qualified staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty record for shifts in June 2007 was inspected to review the number of staff on duty to support residents to meet their needs. Mr Knowles the registered manager currently works for fifteen hours each working week at a Home in Pucklechurch. A minimum of two staff is on duty for a day shift, and one staff member at night. An extra staff member will also work a late shift several days in the week to support residents to be able to attend activities away from the Home.Residents were observed being well supported by the numbers of staff on duty. Staff were calm and relaxed in their work and communicating well among themselves. Based on the evidence from the inspection the number of staff on duty at any time is the minimum number necessary to ensure residents ’ needs are met. Staff reported that the senior support worker and Mr Knowles provide regular structured supervision sessions to assist them in their work and to help them Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 20 to understand residents needs. There were informative records that demonstrated staff supervision sessions take place on a regular basis. The training records demonstrated staff had attended training relevant to the needs of residents over the last twelve months. The staff consulted spoke positively about the training opportunities they take part in. This should help ensure residents’ needs are being met by the assistance of well-trained and knowledgeable staff. However see comments made in the ‘complaints and protection’ section of the report about staff training on the subject of the `protection of vulnerable adults’. Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42. Quality in this outcome area is adequate. Residents who use the service benefit from a generally stable Home. However residents’ health and safety could be better protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 22 Mr Knowles is a qualified learning disabilities nurse. He has a number of years of experience working with people who have learning disabilities. He is registered with the Commission as the manager of the Home. This demonstrates Mr Knowles is considered suitable and qualified to fulfil the role of registered manager. Mr Knowles is currently working fifteen hours of each week at a care Home in Pucklechurch. Mr Knowles was working at that Home on the day of the inspection. Residents and staff at Acshcylst Care Home will clearly benefit when this arrangement has ceased and there is a full time manager working at the Home to provide consistent leadership and managerial support. Residents’ records are kept in a locked metal cabinet in the office. The care records and records relating to the running of the Home were satisfactorily written, legible, up to date, and well maintained. Residents’ financial records were also checked. These were detailed up to date, and satisfactorily maintained. This helps to demonstrate residents’ confidentiality is being protected, and ensures legal records required for the running of the Home are in order. The monthly monitoring visits of the Home that must be carried out by a representative of Aspects and Milestones Trust are being undertaken as required by law. There are records of these visits being sent to us. The records that have been seen, demonstrate that the designated individual responsible for the visits spends time consulting with people and observing staff carrying out their duties. The Trust has carried out detailed quality audits of the Home. However a copy of the audit ‘tool’ could not be reviewed because it could not be located. This was highly regrettable and will be followed up at the next inspection of the Home. The environment looked safe and satisfactorily maintained in all areas viewed. There is a record of the monthly checks of the environment. These checks were up to date and showed that a member of staff checks the health and safety of the environment on a regular basis. Staff go on regular training in health and safety matters including first aid, and moving and handling practices. This should help protect residents ’ health and safety if staff are knowledgeable and well trained in health and safety principles and practices. However staff have not been consistently checking the temperatures of all high risk cooked food before it is served to people to make sure it is hot enough and safe to eat. The fire logbook record was checked and showed the required weekly and monthly tests of fire alarms and fire fighting equipment were being carried out and were up to date. However one member of staff has not attended recent fire safety update training. This training is necessary so that all staff know Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 23 what to do in the event of a fire in the Home, as well as how to minimise fire safety risks. Ashclyst DS0000003390.V336895.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 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 x 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X N/A X 3 2 x Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Schedule 1 Requirement To amend the service user guide to ensure that information relating to the legislation is clear in relation to the Care Home’s Regulations. (Outstanding requirement 03/08/06). One resident’s assessment record must be more detailed. Specifically the reasons why a `baby monitor’ is used, and how this helps maintain the persons safety. One member of staff must attend fire safety update training. This is necessary so that all staff know what to do in the event of a fire. The Home must be kept satisfactorily clean. Specifically action must be taken to reduce the amount of dust on surfaces in bedrooms. Timescale for action 06/07/07 2. YA3 14 01/07/07 3. YA42 23.4(d) 09/07/07 4 YA30 23.2(d) 01/07/07 Ashclyst DS0000003390.V336895.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations All staff should attend regular training on the subject of the `protection of vulnerable adults’. This is to help to increase staff understanding, and to thereby protect the residents from the risk of harm and abuse. Ashclyst DS0000003390.V336895.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. 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