Inspection on 26/07/05 for Bedrock Mews

This inspection was carried out on 26th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bedrock Mews 03/10/07

Bedrock Mews 25/04/07

Bedrock Mews 17/01/07

Bedrock Mews 04/07/06

Bedrock Mews 01/11/05

Bedrock Mews 07/12/04

Bedrock Mews 16/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 1 New Road Stoke Gifford Bristol BS34 8QW Lead Inspector Jackie Hargreaves Announced 26 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 1 New Road Address 1 New Road Stoke Gifford Bristol BS34 8QW 0117 9569473 01454 772171 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Nightingale Care Homes Mr John Michael Gay Care Home for Younger Adults 4 Category(ies) of LD Learning disability, for 4 registration, with number of places 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 4 persons (male and female) aged 18 - 64 years with a learning disability. Date of last inspection 7th December 2004 Brief Description of the Service: 1 New Road (Springfield) is one of four homes operated by Nightingale Care Homes. The home was newly registered with the CSCI in February 2004 to provide accommodation and personal care to four adults with learning disabilities up to the age of 64. At the time of the inspection there were four male service users accommodated in the home with additional complex learning disabilities, mental health and behavioural needs.The home is situated in Stoke Gifford close to the Avon ring road and bus routes. There are retail outlets and shops close to the home. Bristol Parkway railway station is within easy reach of the home. The property is a four bedroom two storey semi detached house. Bedrooms are situated on the ground and first floor. Each bedroom has its own bathroom. Residents have full access to a lounge, kitchen and conservatory/dining area. Currently no residents have physical or sensory needs that required adaptations or equipment. There is a well maintained garden and a summerhouse. There are plans to extend the property and increase the number of residents accommodated from four to six. Building work on a side extension was in progress and an application to vary the homes conditions of registration has been received by the Commission. The application will be considered when the building work has been completed. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection to assess the standards of care and support provided taking into account the aims and principles of the home set out in its Statement of Purpose. The inspection was conducted over one day and not all standards were assessed on this occasion. Requirements and recommendations from the previous inspection were fully reviewed. All four residents accommodated at Springfield had received assessment and services from learning disability, mental health and rehabilitation services. Good communication with residents was an important aspect of their support needs. The registered manager, who is also the registered provider, was not present, however, the assistant manager enabled the inspector to focus on the home’s procedures and management arrangements relating to staffing, staff training and planning with residents to meet their personal and healthcare needs. Residents’ files were inspected. Care/life planning for two residents was scrutinised in detail and checked against care notes and risk assessments for ensuring their personal safety. Residents day-to-day needs and choices and their contribution to the running of the home were discussed with some staff and the assistant manager. During a latter part of the inspection when residents returned from their daytime activities the inspector was able to discuss with them their activities, daily routines and choices. Discussion took place in the lounge and more privately with one resident. Further evidence was gathered from the pre-inspection questionnaire completed by the assistant manager and a comment card received from a relative. Staff were helpful and cooperative throughout the inspection visit and enabled residents to contribute to the process. What the service does well: There are currently four residents accommodated at Springfield. In consideration of the complexities of their needs it was evident that the residents were currently settled and stable and appropriate support was being provided. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 6 Communication with the residents although inhibited by their individual ways of communicating and time available was positive in terms of the support they received and their views of the home. There was evidence of personal development and promotion of choice. These views were fully supported by a residents relative. This home had good record keeping systems in place. Files were well kept and the records required for ensuring the safety and welfare of residents were organised and up to date. Staff training initiatives were being promoted including induction training and training to meet residents mental health and behavioural needs. What has improved since the last inspection? What they could do better: Information on the home has been updated and improved. The home could also improve the service users guide by making it more user friendly for residents with reading difficulties. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 7 Although care/life planning with residents was being improved by implementing a new system current planning should be kept up to date and contain sufficient information to ensure that all needs are met. Residents were encouraged to make personal day-to-day decisions. These decisions could be extended to enable residents to affect how the home is run. The welfare of residents would be improved by ensuring that robust staff recruitment and employment procedures are in place that protects them. Residents activity planning for daily living in the home was good, however, individual plans for day activities (IPs) provided by Nightingale Care Homes could be reviewed to enable residents to have more input into these plans and to know the support they should have from staff working in Springfield to undertake activities. Residents should also have a copy. The staff team appeared to be well motivated, however, their ability to fully translate the aims of the home into their work and ensure the welfare and safety of residents would be greatly enhanced by them receiving sufficient time, direction and support from the manager. In the absence of the registered manager on a day to day basis the assistant manager was working well to ensure systems and day to day operations were in place and kept up to date for the benefit of residents. The lack of recorded input from the registered manager in areas of supervision and operations of the home did not demonstrate the home was being effectively managed by the regisistered manager and must be addressed. There were occasions when residents safety was being compromised owing to insufficient staff being on duty. The service must ensure that sufficient staff are on duty at all times to ensure residents welfare and safety and to meet their needs. 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. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,4,5 A pictorial service users guide would enable prospective residents to make an informed choice about the suitability of the home for their needs. There are admission procedures that include the compatibility of new residents entering the home. The home ensures that conditions of occupancy are considered and agreed with residents. EVIDENCE: Since the previous inspection the proprietor had amended the Statement of Purpose so that it was more specific to the services and facilities provided at Springfield rather than a corporate document. There was evidence of work being undertaken on the service users guide to the home to make it more user friendly. Copies of these documents were available to prospective residents and their representatives. Copies of recent inspection reports were also available and staff spoken with were familiar with the reports. There had been no new admissions to the home for over a year. Admissions procedures assessed at a previous inspection were generally satisfactory although a recommendation was made to ensure that new residents compatibility with others already living in the home was fully considered as part of the evaluation of their settling in period. Since this time the service has introduced guidance on introductory visits that refers to compatibility. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 10 During the previous inspection the inspector required that written terms and conditions of occupancy between the service and residents were available for inspection. These were in place and had been appropriately signed to indicate they had been agreed by the proprietor and the residents. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 The staff team had a good knowledge of residents needs and care planning to meet residents needs was being brought up to standard. Personal risks were assessed and monitored. Residents were encouraged to make decisions, however, the service would benefit from more input by residents on the running of the home. EVIDENCE: Two of the residents files were closely studied and the remaining two in less detail. The files contained examples of newly developed planning formats that were being completed. These were discussed with the assistant manager. The plans detailed aspects of residents personal and healthcare needs and included sections specifying the actions required to enable the person to meet their needs and to monitor their achievements or independence. The plans were an improvement upon existing plans although were in the early stages of development and it was too soon to assess their effectiveness. Two existing care plans lacked specific detail on the recommended actions required to meet some needs and to achieve positive outcomes for residents. However, there was convincing evidence to indicate that these would be 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 12 brought up to standard and the assistant manager had a good knowledge of these needs which she described in positive ways. Guidance had been written for staff on forms of behaviours displayed by residents that were inappropriate or involved personal risks. The guidance included triggers that may make a person angry or upset and the responses required to manage the behaviours. There was good evidence that the guidance was regularly reviewed with residents and where necessary a referral for outside professional help was made. Residents and staff were asked about residents involvement in decision making on life in the home. A range of daily living issues and those relating to wider home management were discussed. There was good evidence that residents were encouraged to make personal day to day decisions such as when to go to bed, what to do in the home, where to go outside of the home and how to handle money. Where residents choices or decisions identified a vulnerability or risk, for example with going out, road safety or money issues, an assessment of the risk had been undertaken and appropriate measures put in place. Residents meetings and questionnaires provided forums for discussion and personal consultation. Minutes of a residents meeting held in June 05 showed that residents were asked about a new extension being built at the home and the forthcoming inspection was discussed. The assistant manager told the inspector that residents had completed questionnaires. One person had asked for darker curtains and these were provided. Less evident was the creation of opportunities for involving residents in meaningful ways on what are currently senior management decisions such as staff selection, menu planning, holiday planning and service development planning. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14 The home enables residents to maintain and develop skills and lifestyles suited to their needs and preferences. Organised activities should be driven by residents abilities and aspirations. Residents were offered an annual holiday although arrangements were not driven by resident choice. EVIDENCE: Individual plans (IPs) evidence activities organised through Nightingale Care Homes day activities at Bedrock Lodge. Daily planners detailed home or community based activities chosen by residents with assistance from key workers. Daily planners were of a good standard and focussed upon meaningful and active structure for residents. IPs did not fully correlate with daily planners or demonstrate the support and resources required or that they were driven by the abilities and aspirations of residents and should be reviewed. Discussions with residents and staff evidenced that residents needs were fully considered when planning daily activities with them. For example, one resident with a need for structure and control over what was happening was supplied with a diary as well as his weekly planner, so there were no surprises. All 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 14 residents received guidance and supervision with domestic routines and to access community facilities such as local shops, retail outlets and library to ensure their safety and develop skills. Two residents had been introduced to a conservation project that offered two-hour work sessions, which they were enjoying. The home had a minibus although residents were also encouraged to access local amenities on foot and use public transport to maintain independence. Personal interests and hobbies were supported such as gardening and bird watching. Residents said they went out on Saturday evenings and on trips. There was a ‘places to go’ file that enabled choices to be made. Less evident were holiday choices. All of the residents were going on holiday to Nightingale Care Homes Caravan in Brean. The assistant manager did not know how the holiday had been arranged and residents had not looked at holiday brochures, which does not accord with the aims of the home or meet with National Minimum Standard 14.4 and should be reviewed. There was good evidence that staff had devoted time and skills to enable residents to achieve personally. For example to develop social skills and confidence. One resident was now sitting in meetings with his social worker. Another person was able to sit with other people when out socially. One resident was more confident in asking for what he wanted and had progressed to handling his own money. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 The home involved residents in their personal care and support in ways they preferred and required. The arrangements for meeting health care needs and the administration of medication were satisfactory. EVIDENCE: Residents had key workers who related closely to them to provide continuity of support and maintain independence. Care plans were also supported by intimate care statements and essential information detailing how each person preferred to receive care and the important things a member of staff needed to know and do to support the person. Recording of medical and health input seen in medication notes and on monthly reports by key workers of residents health needs were of a satisfactory standard and included treatments for specific health needs and health checks. There were no specific health action plans although a new planning format was being developed to incorporate personal and healthcare needs and action plans for meeting needs. None of the residents self-administered medication. The administration and control of medicines records were well organised. Medication was securely stored. The dispensing pharmacist had carried out a check on the home’s system in March 05. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 16 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Complaints and POVA (Protection of Vulnerable Adults) procedures were satisfactory and staff were being made aware of the processes involved to ensure the welfare and protection of residents. EVIDENCE: A complaints procedure that included the contact details of the Commission was available to residents and their representatives. Copies of the procedures were displayed in the homes entrance and on the relatives notice board. The contact details for the Commission were not found in the concerns and complaints section of the homes Statement of Purpose and should be included. Worries and concerns and who to talk to were a regular agenda topic in residents meetings and reinforced opportunities for complaints to be addressed as a group or discussed personally. No complaints had been recorded in the home in the past twelve months. At the previous inspection of the home the inspector required the service to obtain local policies and guidance on the protection of vulnerable adults (POVA) and to ensure staff received up to date training on POVA. This was to equip staff with knowledge and skills to safeguard residents from abuse or degrading treatment. The local policies had been obtained and there was documented evidence that confirmed three staff had received this training and the remainder were on a waiting list. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,28,29,30 The home was clean, comfortable and suitable for its intended purpose. Residents bedrooms and bathrooms were suitable for their needs. Laundry facilities had been improved. Work was being undertaken to extend the property to accommodate six residents. The Commission will be considering an application to vary the homes registration. EVIDENCE: The property is a two-storey semi detached, domestic style house that provides easy access to local amenities and bus services. It is well maintained and offers a comfortable, safe environment for the residents. All residents had single bright and airy bedrooms of a satisfactory standard that met their needs although one bedroom viewed had lightweight curtains without linings. This was brought to the attention of the assistant manager to be addressed. Three bedrooms had en suite toilet and bathing or shower facilities and the fourth had a designated adjacent bathroom. Residents had full access to a 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 19 lounge, kitchen and conservatory/dining area. No residents had physical or sensory needs that required adaptations or equipment. Laundry facilities had been more suitably re-located so that laundry did not need to be taken through the kitchen. The facilities were suitable and the laundry area clean and tidy. There was a well-maintained garden that was used by residents. One resident kept rabbits. The garden was equipped with garden furniture and a summerhouse that was used for smoking. The home was newly renovated and refurbished prior to its registration with the Commission in February 04. There are plans to extend the property and increase the number of residents accommodated from four to six. Building work on a side extension was in progress and an application to vary the homes registration has been received by the Commission. The application will be considered when the building work has been completed. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36 Staff were motivated and the service ensured trained staff supported residents. Staffing arrangements relating to recruitment practices and staffing levels were placing residents at risk. EVIDENCE: The home did not have a full compliment of permanent staff. Two full time staff members were on extended leave. Although generally cover was being provided by care staff working for Nightingale Care Homes there were times when residents safety was being compromised. The duty rota for week ending 23 July 05 was scrutinised and showed that on occasions only one staff member had been on duty between 4pm and 10pm when all of the residents were in the home. There must be sufficient staff on duty at all times to ensure residents welfare and safety and to meet their needs. An immediate requirement was issued to this effect. The assistant manager evidenced how staff training to promote the welfare and safety of residents had been supported since the previous inspection which included National Skills for Care induction training, video training on risk assessments linked to National training standards and five steps to risk assessments. Several in house training sessions on health and safety had taken place. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 21 There was documented evidence to demonstrate that good practice recommendations regarding staff training identified at the previous inspection had been addressed. The service had accessed external training in mental health issues and pursued Learning Disability Award accredited staff training to meet the specific needs of residents. NVQ (National Vocation Qualification) level 2 competency assessment/training was also promoted. Almost half of the staff team had achieved the award. Staff spoken with on the day of the inspection were motivated and knowledgeable about residents personal characteristics and needs. The inspector observed friendly, well developed relationships between staff and residents. A requirement was made at the previous inspection that all staff recruitment/employment documentation be held in the home in accordance with the Care Homes Regulations. Individual staff files were inspected and most were found to be incomplete. Only one staff file contained the required employment documentation. Others were deficient in employment history, previous employer references and copies of CRB clearances. No files contained a job description or contracts of employment. The files must be audited in line with Schedule 2 of the Care Homes Regulations and National Minimum Standard 34 to avoid further action being taken by the Commission. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,41 The service failed to demonstrate adequate direction and support for the staff team to ensure that the health, safety and welfare of the residents was promoted and protected. EVIDENCE: Examination of the staffing rota and arrangements for effective running of the home strongly indicated that the manager was not fully available during normal working hours to provide leadership and direction to the staff team and the responsibilities of managing the home had fallen to the assistant manager. Evidence would suggest the assistant manager was competent and had worked hard to meet the requirements and recommendations in the previous inspection report within the scope of her responsibilities, which were not reflected in her job description. The absence of the registered manager had also resulted in the assistant manager receiving no formal supervision. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 23 It is a requirement that the hours worked by the registered manager are clearly recorded and available for inspection and records are kept of the work performed by the manager. It is further recommended that management arrangements in the home be reviewed to encompass current management practices undertaken by the assistant manager. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x 3 3 3 Standard No 11 12 13 14 15 16 17 3 2 3 2 x x x Standard No 31 32 33 34 35 36 Score x 3 1 1 3 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1 New Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 1 x x 3 x x D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 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 33 Regulation 18(1)(a) Requirement The service must ensure there are sufficient staff on duty at all times to meet the needs of residents and ensure their safety. The registered person must ensure that staff documentation is held in the home in accordance with the Care Homes Regulations. The hours worked by the registered manager must be clearly recorded and available for inspection and records kept of the work performed by the manager. Staff must receive formal supervision from the registered manager at least six times a year. Timescale for action Immediate 2. 34 19 3. 38 17 (Schedule 4) 1.10.05 previous timescale 01.04.05 not met 01.10.05 4. 36 18(2) 01.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 1 Good Practice Recommendations The Service Users Guide to the Home should include D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 26 1 New Road 2. 3. 4. 5. 6. 38 38 8 6 12, 14 pictures to enable prospective residents with reading difficulties to see what the home has to offer. Management arrangements in the home should be reviewed to encompass current management practices undertaken by the assistant manager. Management hours worked by the manager should be sufficient for effective management of the home and ensure leadership and direction for staff. The service should develop ways of promoting residents input into the running of the home The service should ensure that residents care/daily living plans are kept up to date. Individual plans (IPs) should be reviewed to demonstrate that they are driven by residents abilities and aspirations and include the resources and staff support required. 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 300 Aztec West Almondsbury Bristol BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 1 New Road D56 D05 S58581 New Road V229609 260705 Stage 4.doc Version 1.30 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!