Inspection on 01/08/06 for Byways

This inspection was carried out on 1st August 2006.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Byways 23/10/08

Byways 06/11/07

Byways 24/10/05

Byways 05/05/05

Byways 07/12/04

Byways 07/07/04

Byways 30/03/04

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 Byways 80-82 London Road Warmley South Glos BS30 5JL Lead Inspector Odette Coveney Key Unannounced Inspection 1st August 2006 09:30 Byways DS0000003400.V304543.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 Byways DS0000003400.V304543.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. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byways Address 80-82 London Road Warmley South Glos BS30 5JL 0117 9612426 0117 9709301 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 To be appointed Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 8 persons aged 18 years and over. May include persons aged 65 years and over Date of last inspection 24th October 2005 Brief Description of the Service: Byways is a care home that provides accommodation and support for eight people with learning disabilities and additional needs. It is operated by Aspects and Milestones Trust, a non-profit making Trust. The home is situated in Warmley, five miles from the centre of Bristol. It is approximately a twenty-minute walk from a range of shops and the local bus service. The property is a two storey; extended detached house situated in good-sized well-maintained gardens that are fully accessible. The home provides single rooms with wash hand basins. There is ground floor accommodation for two service users. All other bedrooms and a staff sleeping in room are situated on the first floor. There is a passenger lift between floor levels. All areas of the home are accessible to service users. Hallways and corridors are spacious and doors have a clear opening width to accommodate wheelchairs. The home has assisted bathroom facilities and a separate toilet on each level. One Bathroom has a shower. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and also to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included observation of individuals and views of staff. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for four of the individuals were reviewed. Recruitment and selection records of staff were also viewed. At the previous inspection that was undertaken in October 2005 seven requirements and six recommendations were made, all of these were reviewed at this inspection and following an evaluation of the information available it was found that all of these had been met. What the service does well: What has improved since the last inspection? The management and staff at the home have worked diligently in order to meet all of the requirements and recommendations from the previous inspection. The home is now better placed to meet the Care Homes Regulations 2001 as all staff records are kept in the home and are available for inspection in line with Schedule 4 of the regulations. Also regulation 26 reports are forwarded to the Commission for Social Care Inspection, these provide some insight into the day-to-day management and running of the home. The Trust has demonstrated a commitment to providing a well maintained environment as the ceilings in the ground floor corridor had been repainted to remove water stains and also as a contractor had checked a light fitting in the corridor, ensuring that it was safe. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 6 Those living at Byways are better informed of their costs in respect of the use of the home’s vehicle as contractual documents had been amended and updated where required. Residents at the home are better supported by staff with their medication administration as staff members who deal with unwanted medication dispose of these in the correct manner. Also as medication side effect records have been updated and reviewed. The safety of residents has been fully evaluated as the home had undertaken a risk assessment in respect of the use of the homes vehicle. The home has also formatted the risk assessments and they are of a consistent standard. Staff can be confident that polices and procedures within the home are current and the provision for resident’s is current and adequate, as the Trust have updated the headings on both the operations manual and the health and safety manual and the headings reflect the current status of the Trust The home is able to demonstrate that the holistic needs and wishes of residents in respect of their healthcare are being reviewed and recorded and the home has started developing health action plans for those living at the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Byways DS0000003400.V304543.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 Byways DS0000003400.V304543.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): 1, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Contracts are in place, which record the rights and responsibilities of both individuals and the Trust. EVIDENCE: The inspector has seen at previous inspections that the home has in place a clear and comprehensive statement of purpose. This document outlines the facilities and services provided at the home and details how individuals will be supported. Some discussion about this document took place and the manager is aware that this document will need to be reviewed and updated in order to reflect the new management status, once the manager has undergone his ‘fit persons’ interview with the Commission this will be completed and a copy of this amended document will be forward to the Commission. At this inspection contracts were viewed for four residents. This was to review the requirement made at the last inspection that was to ensure that the statements of terms and conditions had been amended to reflect current transport costs and also that these documents were updated to reflect CSCI details. These documents contained all of the required information and had been recently reviewed. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 9 Byways DS0000003400.V304543.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, 7, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear plans of care are in place with individuals being supported to make decisions about their life within a risk managed framework. Information is handled appropriately. EVIDENCE: The care documentation for four of those living at Byways was examined during this inspection. It was evident that the care planning information had been generated from a care manager’s assessment as well as the homes initial assessment. These cover all aspects of personal and social support and healthcare needs as well as individual’s needs and wishes. Each person’s records set out how current and anticipated specialist’s requirements will be met through positive planned referrals to identified services. Records viewed at this inspection included clear information on individuals preferred form of communication, individuals had in place personal care statements stating how they wished to be supported. Information was in place to demonstrate that time had been spent with individuals through person Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 11 centred planning processes in order to look at essential lifestyle plans that had outlined individuals short term, medium and long term goals with information to direct staff on how these were to be met. There was clear evidence within care records that evidenced that individuals are supported by staff in order to make decisions about their lives, that they have been given appropriate assistance and that support had been tailored to the needs of the individuals in order that they can make an informed decision. It was clear that, where able, individuals had been consulted and their input within assessment processes had been recorded in care records. Each person’s plan sets out in detail the action which needs to be taken by staff to ensure that all aspects of health, personal and social care needs of residents are met, records were seen to be detailed. Staff knowledge on individual’s support needs and aspirations were sound. It was noted at the last inspection that although all of the residents had risk assessments in place there were differing formats in use. All of the residents use the home’s car with support from staff yet no risk assessment was in place. At the previous inspection a requirement was made that risk assessments must be completed on the use of the homes vehicle these were seen by the inspector and were found to be fully comprehensive and covered all areas of potential risk and how these could be avoided. It was further recommended at the last inspection that consideration be given by the home to formatting all risk assessments in the same way. The home has made some significant improvements in this area and therefore this standard had been met. A recommendation was made at the last inspection that staff clearly identify who has made entries into care records. A review of this recommendation found that entries within individuals records had been well written, with positive language used will entries identifiable as to who had written them. The inspector saw that the terms ‘encouragement’, ‘offer information’ and ‘support’, ‘guidance’ and ‘encourage choice’ were incorporated within care documentation demonstrating a commitment from the staff team to promote individual choice and respecting the individual’s as adults. During the inspection staff were heard to be using such terminology when talking with those living at the home. Through observation of responses when dealing with individuals it was evident that staff have a good understanding of individual’s support needs, this was evident from the positive relationships, which have been formed between those living at the home and staff. Records are stored safely and are able to be locked away. The home has a clear confidentiality policy that covers aspects of written and verbal information. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 12 Byways DS0000003400.V304543.R01.S.doc Version 5.2 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 the following standard(s): 11, 13, 14, 15, 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and community presence are tailored to the specific wishes and abilities of the individuals. These were well managed and provide daily variation and interest for the people living in the home. Relationships with others are maintained with support from the staff team. EVIDENCE: All of those in the home have learning disabilities, and some have limited communication skills. However, the information seen within care records demonstrated that individuals are encouraged to participate where appropriate in making choices and decisions upon day-to-day issues which affect their well being. Staff have become skilled at recognising how choices are made, for example, through observation of individual’s language, expressions and individual’s behaviour. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 14 Staff continue to support those living at the home to maintain family links and friendships inside and outside of the home; information seen linked into the care plans in place. In individual’s files was information of significant and important relationships and their contact details. Individuals are well supported and encouraged to make decisions about their lives in areas of personal development and social and leisure activities. Key workers meet with individuals to discuss choices and plan together how these will be met. Personal relationships were discussed with the manager who was able to demonstrate that individuals would be supported as needs arose whether this be by providing practical information, support or by contacting other appropriate agencies. Byways DS0000003400.V304543.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported in their preferred manner and individual’s physical, emotional and healthcare needs are well met. EVIDENCE: A support worker was asked if individuals are able to choose when they get up and when they go to bed. The staff member was very clear that there are no set routines for individuals and that those living at Byways make this decision for themselves. A staff member said that the time that individual’s get up is very much dependent on what they have planned for the day and that the staff team offer a flexible approach tailored to meet the needs of individuals. Care documentation provides clear information to staff to inform and guide their practice, the records provide information to show that individual’s are supported in their life in the manner they require and prefer. A recommendation was made at the last inspection that consideration be given to the home developing Health Action Plans for those living at the home. The inspector saw that some progress had been made in this area and the manager Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 16 has incorporated the use of symbols and pictures and documents had been written in an individualised, person centred way. There were records of visits to the doctor and other primary healthcare support services and these were up to date and sufficiently detailed. The inspector saw correspondence from health professionals, including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required, examples of this includes community learning disabilities team, hospital out patients, chiropody, dentist and occupational therapists demonstrating a ‘multi disciplinary’ approach. Staff escort individuals to healthcare appointments in order to support them. The home has in place robust medication policies and procedure in the administration, disposal and staff responsibilities in this area. Records detailing the administering of medication were found to be accurate, photographs of service users were in place. The inspector saw that professional advice is sought and service users medication is reviewed on a regular basis and changed as required. At the previous inspection medication administration records at the home were examined and it was found that records relating to side effects of medication had not been reviewed or updated for some time. These records were reviewed at this inspection and it was found that the records had been updated. Medication had been evaluated and side effects identified and recorded. It was noted at the previous inspection that medication was not being disposed of appropriately. At this inspection records seen showed that medication is now returned to the pharmacist for appropriate disposal. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s can be confident that their complaints would be listened to and taken seriously and staff demonstrated a clear understanding in this area with clear policies and procedures in place. Those living at the home are protected from any potential of abuse due to staff training and understanding in this area. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals, this includes a protection of vulnerable adults policy and a protection of vulnerable adults policy that has been developed by South Gloucestershire’s Community Care department. This was on prominent display in the office. A staff member was asked what their actions would be should they have any concerns over a vulnerable adult, they were very clear on their responsibility to ensure the protection of those within their care and would have no hesitation to report to their line manager. The Commission for Social Care Inspection has received notification of incidents that have affected individual’s well-being at the home, the information provided shows that individuals had been supported in an appropriate manner. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 18 Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 19 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, 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are areas in the home that require redecoration and renewal. EVIDENCE: Byways is registered as a care home for those with a learning disability and is able to accommodate eight individuals. There have been no changes in the services and facilities provided at the home since the previous inspection. The location and layout of the home is suitable for its intended purpose. The home is a large extended detached house with accommodation set over two floors. There is a lift for access to the first floor. The home is located on a busy road and is within close distance of the local shopping areas of Staple Hill and Kingswood. The home is on a main bus route and has easy access to both the M4 and M5 motorways. Individual’s bedrooms are appropriately furnished with individuals being encouraged to bring in personal effects in order to make their room more Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 20 ‘homely’. Rooms seen had appropriate furniture and fittings with photographs, plants, pictures and ornaments enhancing these rooms. It was noted at the previous inspection there was some water staining on the ceiling from when the boiler leaked therefore it was recommended that this be painted in order to provide a well maintained environment at the home. It was also noted at the same inspection that in this same area that a light had no bulb, the deputy manager was unsure if this was due to it being unsafe. It was required that an electrical contractor checks this fitting to ensure its safety. These issues had been addressed. There are individuals at the home who require support from the staff with their continence needs. Generally the home was clean and tidy and free from odour at the time of the inspection. It was noted that there are some areas within the home that are in need of improvement, the lounge carpet is well worn and stained and requires replacing, the kitchen décor is looking ‘dated’ and it is recommended that consideration is given to the redecoration of this area. The ceiling light in the kitchen requires cleaning. There are appropriate bathing and toilet facilities for individuals use, however it was noted that the lock on the first floor bathroom door was broken, it is required that this be replaced in order to maintain the dignity of residents. Continence aids are stored in the main toilet area and it is understood that this provides convenience and ease of access however consideration should be given to improving the storage of these items in order to improve the dignity of residents. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users living at Byways benefit from competent staff that are trained and are recruited in line with the organisation’s policies and procedures. Records of staff training could be improved upon. EVIDENCE: There are clear aims and values in this home, which are service user focused and centre on the choice, rights and self-determination of the individual. Staff were able to clearly demonstrate this philosophy and it was evident that meaningful relationships had been forged between the staff and service users in the home. Each individual has two key workers to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individual’s and have worked together with them and others in order to identify the needs of a resident and then support the person in achieving their goals and future aspirations. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 22 It had been noted at the previous inspection that some progress had been made to hold staff recruitment documents on the premises, however at the previous inspections in October and May 2005 it was evident that all of the documents as outlined within schedule two were not in place, therefore the requirement made at the previous inspections had not been met. The recruitment and selection documents for staff members were reviewed at this inspection and the requirement was found to be met. Those living at the home can be assured that staff employed have been done so following clear and robust recruitment practices and the implementation of organisational policies and procedures. The inspector saw that the home has in place employment documents for staff, these were available and viewed at the inspection, this included references, completed application form a criminal records bureau check and contracts of their employment terms and conditions. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team and their own personal role and accountability. The atmosphere at the home at the time of the inspection was calm and relaxed with individual’s looking clearly at ease and ‘at home’. Training records demonstrated that staff are supported to undertake sufficient, appropriate training in accordance with their role and responsibilities. However some improvement is recommended for the home’s internal recording systems in order that these fully reflect all training and instruction given. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 23 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, 38, 40, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Both the manager and deputy manager at Byways are qualified, skilled and experienced. The management ensure an open and inclusive atmosphere is present in the home, which is run in the best interest of those living at the home. Health and safety of those living and working at the home is well managed however improvements are needed in respect of the recording of fire training and instruction. EVIDENCE: Throughout the inspection process, as during previous inspections Mr Parry was able to demonstrate that he is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. He has a sound understanding of the diverse and complex needs of those living at Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 24 Byways and is committed to ensuring that staff are working with individuals in a person centred way. The fire logbook is well maintained with clear information in place to demonstrate that fire fighting and detection equipment is checked at appropriate intervals by staff at the home and by specialist fire contractors. The last fire drill took place at the home recently and had been well recorded, records of initial fire instruction had not been recorded and a requirement that better recording in this area was made. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at the home. Individual’s rights and best interests are safeguarded by the organisational policies and procedures. A recommendation was made at the last inspection that the headings on these must be updated. This has been addressed A requirement was made at the last inspection that improvements must be made in forwarding the regulation 26 reports of visits made to the home; this has improved and reports are forwarded on a consistent basis. Some discussion took place surrounding the importance of the information recorded within these reports It was noted at the last inspection that the home’s vehicle administration record had not been updated for sometime and a recommendation was made that this record be reviewed. This document was seen at this inspection and it was found that this record along with new guidance had been well written and better maintained. Formal supervision with staff is taking place on a regular basis. A staff member spoke of the purpose of these meetings in order to ensure that individuals are supported according to their preferred routines and preferences and also so that staff are guided and given appropriate information in order to fulfil their duties. Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 25 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 3 2 X 3 X 4 X 5 3 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 2 25 3 26 3 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 X 3 2 3 x Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard YA41 YA24 YA30 YA27 Regulation 23(4) d 16(2) c 23 (2) p 16 (2) b Requirement Records of fire instruction to be better maintained. Lounge carpet to be replaced. Kitchen ceiling light to be cleaned. Lock on toilet door to be repaired. Timescale for action 01/09/06 01/12/06 01/09/06 01/09/06 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. 3. Refer to Standard YA28 YA29 YA41 Good Practice Recommendations Consideration to be given for the redecoration of the kitchen. Consideration to be given to better storage facilities for continence products. Staff training audits to be completed. Byways DS0000003400.V304543.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: 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 Byways DS0000003400.V304543.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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