Inspection on 24/10/05 for Byways

This inspection was carried out on 24th October 2005.

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 2 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 01/08/06

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 Unannounced Inspection 24th October 2005 09:30 Byways DS0000003400.V264135.R01.S.doc Version 5.0 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.V264135.R01.S.doc Version 5.0 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.V264135.R01.S.doc Version 5.0 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 Ms Tracy Michelle Wetherald Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Byways DS0000003400.V264135.R01.S.doc Version 5.0 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 5th May 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.V264135.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided, and to monitor the progress in relation to the four requirements and two recommendations from the last inspection that was conducted in May 2005. The inspection took one day to complete. During the process all of those living at the home, four staff and the deputy manager were spoken with. The inspector looked around some of the building and a number of records were examined. Since the last inspection the manger has left the home, the position is being left open for six months. The Commission were notified of this extended absence, a letter outlined the arrangements which have been made for the running of the home during the absence in order to ensure that the needs of those living at the home are met and that provisions to ensure the continuity of care and service delivery are in place. What the service does well: What has improved since the last inspection? What they could do better: The home would be better placed to meet the Care Homes Regulations 2001 if all staff records were kept in the home in line with Schedule 4 of the regulations. Similarly if regulation 26 reports were forwarded to the Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 6 Commission for Social Care Inspection and are completed fully and legibly the Commission would have a clearer view of the day-to-day management and running of the home. This has been a requirement for the previous two inspections and is not reflective of professional practice. Those living at the home would be accommodated in a well maintained environment and the Trust would demonstrate that it is committed to providing a well maintained environment if it ensured that the ceilings in the ground floor corridor are repainted to remove water stains and also if a contractor checks a light fitting in the corridor to ensure that it is safe. Those living at Byways would be better informed of their costs in respect of the use of the home’s vehicle if these documents were amended and updated. Any outstanding monies owed to residents must be returned. Residents at the home would be better supported by staff with their medication administration if staff members who dealt with unwanted medication disposed of this in the correct manner and also if medication side effect records were updated and reviewed. The safety of residents would be fully evaluated if the home undertook a risk assessment in respect of the use of the homes vehicle. Consideration should also be given to formatting the risk assessments in order that they are of a consistent standard. In order that staff are confident that polices and procedures within the home are current and the provision for resident’s is current and adequate, it is recommended that the Trust update the headings on both the operations manual and the health and safety manual in order that the headings reflect the current status of the Trust In order to demonstrate that the holistic needs and wishes of residents in respect of their healthcare are being met it is recommended that the home considers developing health action plans for those living t the home. 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.V264135.R01.S.doc Version 5.0 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.V264135.R01.S.doc Version 5.0 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, 2, 3, 5 Individual’s aspirations and needs are identified and well met. Terms and conditions and the service users guide provide clear information of individual’s rights and what they can expect from the organisation, however improvements to the contracts must be made. EVIDENCE: There is a stable group of people who have lived at Byways for sometime and therefore there have not been any new admissions to the home. The Trust has a robust admissions procedure, which is very much tailored to the individual. People are only admitted to the home only after a full assessment of their needs and wishes has been undertaken and then the home must be able to demonstrate that they have the skills, resources and facilities in order to meet identified needs. These are recorded on a care plan and provide a guide for staff to follow and build upon. Each resident had a copy of the service users guide; this incorporates the statement of purpose outlining the aims and objectives of the home, the facilities, staffing, the admissions process and how to make a complaint. The inspector saw that each resident has a copy on file of their terms and conditions of placement. These documents are detailed and clearly outline the rights of those living at the home. Each document had been explained to the Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 9 resident and had been signed by them and a staff member. It was noted that this document still referred to the National Care Standards Commission. All of the contracts had been completed within the last twelve months. The terms and conditions record the fees that individuals are expected to pay and also what individuals are expected to pay for themselves. It was noted that residents had within their contract an amount they were expected to pay in respect of the lease of the home’s vehicle; the amount recorded is not correct and must be reviewed. Statements of terms and conditions are required to be amended to reflect current transport costs. This document is to also be updated to reflect CSCI details. Byways DS0000003400.V264135.R01.S.doc Version 5.0 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, 8, 9 Individuals assessed and changing needs are clearly identified and are met; individuals are consulted and supported to make decisions, which affect their life. Risks are identified, however these can be improved upon. EVIDENCE: It was evident that the registered manager and staff members had developed with each resident an individual care plan, these records clearly showed that the resident had been at the centre of the process and reflected individual choices, routines and needs with further information recording how the care home would meet these needs. Records were very detailed and included information on how individuals communicate, how they wish to be supported in both a practical, physical and emotional way in areas such as health, social and relationships. Individuals had been consulted in order that personal care statements recorded what individuals wanted. Each person at the home has received one to one support from a core team of staff to be the focus at a person centred workshop. These look at areas which are essential and important to the resident and outline what staff need to know and do in order to support them. These plans have been implemented and followed and are reviewed on a regular basis to ensure they are still relevant. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 11 One of the residents at the home is currently being supported by the home and also by external agencies in order to look for a more suited environment. It is anticipated that this will be a form of sheltered housing, the deputy manager allocates time with this resident on a monthly basis to explore the options and issues associated with this. The home has identified safe working practices for residents which have been based on an assessment of their individual need and choices, those seen included eating and drinking, out in the community and road safety. All of the assessment seen had been reviewed on a regular basis. Manual handling profiles were in place and all contained sufficient information to support residents safely. 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 form staff yet no risk assessment was in place. It is required that risk assessments be completed on the use of the homes vehicle It is further recommended that consideration be given by the home to formatting all risk assessments in the same way. Each resident had in place a daily diary outlining what activities they have participated in during the day and how they have been within themselves. It was found that not all staff members have written their name or initials when making an entry; it is recommended that staff clearly identify who has made entries into care records in order that they ‘own’ what they have written. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16, 17 Resident’s rights and responsibilities are respected and they are well supported with their own personal development and are empowered to make choices in areas of their lives including menu, social and leisure activities. EVIDENCE: Evidence in care records showed that staff support residents to become part of and participate in, the local community in accordance with assessed needs and individuals wishes. Staff have helped residents with their integration into community life through making use of local facilities and activities such as shops, pubs, leisure centres and places of worship. Activities and outings are organised in accordance with individuals expressed wishes. One resident likes animals and recently visited Longleat. Another resident enjoys craftwork and took pleasure in showing the inspector items they had made. One of the staff members told the inspector that they have been allocated three hours, three days each week in order to co ordinate activities for residents. From their enthusiasm it was evident that this was something from which they received a great deal of job satisfaction. They gave real examples of how residents have benefited from one to one quality time being supported with fulfilling activities undertaken at their pace. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 13 During the inspection one of the residents went out shopping for clothes and enjoyed showing the staff on their return the items they had purchased and chosen. In the afternoon two residents attended bingo. Residents attend college each week and have taken up sessions of gardening and cookery, areas they enjoy. Other activities seen in individuals daily diaries included; music session, swimming, garden parties, visiting family and friends, a holiday to Minehead, bowling and visiting places of local interest. Ones of the residents had said that they wanted a cat, following full consideration on the impact on the home and after consultation with the others living at the home this was arranged. The resident is supported to care, feed and look after their pet. Two of the residents are looking forward to a holiday in Germany to visit the Christmas markets in December. The inspector noted that meals were unrushed and relaxed. There was positive interaction between staff and residents. Alternatives were available. Daily diaries recorded that residents have a nutritional varied diet. The kitchen was found to be clean and tidy. The fridge and store cupboards were well stocked with a good range of foods. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Individuals are supported in their preferred manner and individual’s physical, emotional and healthcare needs are well met. Improvements are required in the recording and disposal of medication. EVIDENCE: Relationships between staff and those living at the home were observed to be respectful and friendly at the time of this visit. The care documentation in place sampled provided clear guidance for staff on how they should support individuals with their personal care, it had recorded individual’s preferences and the assistance required with personal hygiene and personal support. The inspector saw in care records that, when required, individuals had access to the relevant health professionals. The inspector saw evidence to indicate that the home is aware of the importance of preventative health care. For example individuals are supported to attend appointments and health screening. Staff escort individuals to all appointments. Records clearly showed that individual’s health, both on a physical and emotional level are monitored and appropriate action taken; for example there are individuals who have epileptic seizures while other residents have been supported to attend hospital appointments. Resident’s healthcare is monitored and advice about changes in medication and appropriate guidance is sought. At the time of the inspection Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 15 the deputy manager was in the process of arranging flu vaccinations for all those residents who wanted this. There is no one at the home who is able to self-administer their own medication and all are supported with this by staff at the home. Byways operate a monitored dosage system for the administration of medication that is delivered at regular intervals by the local pharmacist. Records held were examined and it was found that medication had been signed for by staff however records relating to side effects of medication had not been reviewed or updated for some time. It is required that this record is updated in order to ensure that all medication has been evaluated and side effects identified and recorded. Through examination of records it had been written that medication had been ‘disposed of’ when the deputy manager was asked about this she confirmed that medication had been dispensed of via the sluice. This practice must stop and all medication must be returned to the pharmacist for the appropriate disposal. Some discussion took place with the deputy manager about the governments document issued by the Department of Health, Health Action Plans. The deputy manger had a copy of the document and the benefits for those living at the home were discussed. It is recommended that consideration be given in developing health action plans for those living at the home. One of the residents has died since the last inspection, from discussion with the deputy manager it appears that the situation was handled with sensitivity and respect. All of the residents went to the funeral and were supported by the staff team during the difficult time. Records are well maintained of individual’s wishes and preferences in the event of their end of life. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents are listened to and their views are respected. Robust procedures are in place in order to protect residents from abuse and neglect. 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 clear complaints procedure. There are processes in place for staff who wish to report bad practice such as the organisation’s ‘whistle blowing procedure’ and the ‘do the right thing policy’. A copy of the complaints procedure is on each resident’s file and evidence contained within this shows that this has been explained to residents. This procedure is written clearly and gives information in a pictorial format on ‘who can make a complaint’, ‘why complain?’ and records what happens when a complaint is made including who will deal with it, the timescales involves and how individuals will be supported. This is an informative guide for residents. Information on how to make a complaint or raise any concerns is included within the service user’s guide and also within the homes statement of purpose and individual’s contracts. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 29, 30 The quality of furnishings and fittings in the home is good and overall a warm comfortable environment has been created ensuring individuals needs are met, however improvement is required to ensure that areas of the home are well maintained. EVIDENCE: Byways is a care home operated by Aspects & Milestones Trust, to accommodate up to eight people with learning disabilities. Western Challenge maintains the Building. 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 registered to provide a service for eight people. There are currently six people living at the home. The home was on the whole found to be well maintained, comfortably furnished and homely in appearance. There is a lounge area, a sunroom extension and a dining room for individual’s use. Communal areas for residents use were enhanced by the array of soft furnishings, plants and pictures and ornaments making it homely. Those living at Byways were seen making full use of all the areas provided. A staff member explained why pieces of material were draped over the curtains, Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 18 this is because new curtains are being purchased and residents were being supported to choose the fabric, design and colour. There are some aids and adaptations throughout the premises, including wheelchair access to the front and rear of the house, there are toilet aids, continence aids, various grab rails and an emergency call bell system. It was seen in care records that an individual has received information and support from the disabled living centre in order that alternative seating options could be offered to them. As noted at the previous inspection two ceilings on the ground floor have been re-painted, however there is some water staining on the ceiling from when the boiler leaked therefore it is recommended that this is painted in order to provide a well maintained environment at the home. It was noted in this same area that a light had no bulb, the deputy manager was unsure if this was due to it being unsafe. It is required that an electrical contractor checks this fitting to ensure its safety. The atmosphere at the home at the time of the inspection was calm and relaxed with individuals looking clearly at ease and ‘at home’. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 There is a competent staff team who receive appropriate training in order to meet the needs of residents and for their own personal development. Recruitment and selection practices within the organisation are robust however improvements are required in order that the inspector can access these records. EVIDENCE: There are no vacancies amongst the staff team and have not been for some time. Staff are provided with clear job descriptions, which outline their roles and responsibilities and what the organisation’s expectations are of them. Staff records show that they receive regular training, which is appropriate to the service provision at Byways. Training which had been undertaken by staff recently has included: Manual handling, first aid, basic food hygiene, values training, person centred planning, epilepsy awareness training and fire safety training. A staff member who is currently in the process of undertaking a National Vocational Qualification in care told the inspector how much they have enjoyed the award and of the benefits there has been to these living at the home. Both the deputy managers are assessors for the NVQ process and support staff members in achieving their award. There are two staff members who have completed an NVQ at level 3. Two staff members are in the process Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 20 of achieving this award, and another staff member will be enrolling in November. Another new member of staff told the inspector about the induction training they had undertaken and how supported they had felt by both the home’s manager and the organisation in order to equip them with the skills they need. Another staff member said ‘I thoroughly enjoy my job, every day is different and very rewarding’. It had been noted at the previous inspection that some progress had been made to hold staff recruitment documents on the premises, however at that inspection and on this occasion it was evident that all of the documents as outlined within schedule two were not in place, therefore the requirement made at the previous two inspections has not been met and will be further reviewed at the next inspection. Should non-compliance to meet the regulation be found at the next inspection enforcement action may be considered if no reasonable explanation can be given. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 45 Residents benefit from a safe, well-run home and can be assured that their views and choices underpin the service provision at the home. Individual’s rights and best interests are safeguarded by the organisational policies and procedures however the headings on these must be updated. Improvements must be made in forwarding the regulation 26 reports of visits made to the home. EVIDENCE: The manager Tracy Weatherald has been granted an extended absence from the home and her post is currently being covered jointly by the two deputy managers, the arrangements appear to be adequate at this time and will be further reviewed at the next inspection. At the inspections undertaken in December 2004 and May 2005 a requirement was made that records of visits on behalf of the registered provider must be forwarded to the Commission for Social Care Inspection. This has been an ongoing issue and reports are only forwarded when a request by the inspector to the registered provider has been made. There are copies of the reports in Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 22 place at the home and the deputy confirmed that these visits are undertaken each month however it remains that these are not being forwarded to the Commission and therefore remain in breach of the regulations Accident reports for individuals living at the home were viewed at this inspection; incidents had been well recorded, dated and signed. From the information seen it was evident that situations were handled effectively and residents are supported in the appropriate manner. The fire logbook evidenced that the home tests and checks the system at the appropriate intervals and that staff are receiving sufficient, appropriate fire safety instruction. From examination of maintenance surveys and contracts there was evidence to show that equipment, boilers, gas safety and portable electrical appliances are checked on an annual basis. The home has a record in respect of the vehicle used by residents and staff at the home, this records information about the insurance, servicing and MOT, this record had not been reviewed or updated for sometime. It is recommended that this record be maintained in order to provide accurate information on the safety of the vehicle. It is also required that the home undertake a risk assessment in respect of the use of the vehicle to demonstrate that all factors surrounding the safety of both residents and staff have been considered. The Trust has in place extensive policies and procedures manuals in order to provide information and to direct staff, however it is recommended that the operational manual and the health and safety manual be updated in order to reflect the status of the Trust. Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X 2 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Byways Score 3 2 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 3 2 3 DS0000003400.V264135.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA 20 YA34 Regulation 13(2) 19(b) Requirement Medication side effect records to be reviewed and updated. All staff recruitment documentation to be held at the home and be available by the CSCI at all times. Light fitting to be checked by contractor Ensure that copies of the monthly visits undertaken by a representative of the is forwarded to the CSCI. Statement of terms and conditions to be amended to reflect current transport costs. This document to also be updated to reflect CSCI details. Risk assessments to be completed on the use of the homes vehicle. Medication must be disposed of correctly. Timescale for action 24/11/05 24/11/05 3. 4. YA 24 YA39 23 26 24/11/05 24/11/05 5 YA 5 5(b) 24/12/05 6 7 YA 9 YA 20 13(4) a 13(2) 24/11/05 24/11/05 Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 25 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. 4. 5. 6. Refer to Standard YA24 YA 40 YA 19 YA 9 YA 42 YA 6 Good Practice Recommendations Water stains on ceiling in corridor to be re painted. Headings on polices and procedures to be changed in order to reflect current status Consideration to be given in developing health action plans for those living at the home. Consideration to be given by the home to formatting all risk assessments onto the same format. The homes vehicle administration record to be reviewed. Staff to clearly identify who has made entries into care records Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Byways DS0000003400.V264135.R01.S.doc Version 5.0 Page 27 - 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!