CARE HOME ADULTS 18-65
Byways 80-82 London Road Warmley South Glos BS30 5JL Lead Inspector
Odette Coveney Announced 5 May 2005
th 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. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Byways Address 80-82 London Road, Warmley South Gloucestershire BS30 5JL 0117 9612426 0117 9709301 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust 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) Ms Tracy Michelle Wetherald Residential Care Home for Younger Adults 8 Category(ies) of Learning Disability (8), Learning disability over registration, with number 65 years of age (8) of places Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: May accommodate up to 8 persons aged 18 years and over. May include persons aged 65 years and over Date of last inspection 07/12/04 Unannounced 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 D56 D05 YA AV S3400 Byways V217282 050505 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 conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the eleven requirements and three recommendations from the last inspection that was conducted in December 2004. The inspection took place over seven hours. During the process four residents, five staff, the registered manager, the deputy manager and visitors to the home were spoken with. The inspector looked around some of the building and a number of records were examined. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need the care you get?’; a copy of this was forwarded to the home to be put on the homes notice board. The inspector has also arranged to visit the home again on 23rd May to speak with a resident and complete a resident comments card in order to gather some feedback on what the person thinks about the home. What the service does well: What has improved since the last inspection?
There have been a number of significant improvements since the previous inspection. The home has reviewed and updated the statement of purpose for the home; this document provides both practical information as well as information on
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 6 how the service provided at Byways will ensure that individuals needs and choices will be met. The home has in place some staff recruitment records and evidence of Criminal Records Bureau Checks and references for staff, however not all records were available for inspection and therefore the requirement made at the last inspection remains and will be monitored at the next inspection. The home has developed comprehensive manual handling risk assessments for all residents these have been tailored to the needs of individuals ensuring that moving and handling and activities of daily living are undertaken in a safe manner without imposing restrictions on residents activities. The home has undertaken a complete review of the fire safety procedures in place at the home in order to ensure the safety of residents and staff; the home has re-written the fire procedure for the home and completed a detailed fire risk assessment with a photograph of each resident and a record of how each individual would/would not respond and how staff are to support them in the manner most appropriate to them. The home has also developed effective systems to monitor the frequency of staff fire instruction, weekly and monthly fire safety checks. Clear evidence was in place to show that residents personal effects are well audited and that new items purchased are added to their inventories. The home has in place a sound quality audit tool that has been based on seeking the views, wishes and choices of the residents, results influence the action plan which was seen to have been tailored to individuals. Some areas of redecoration have taken place since the last inspection, two ceilings have been re-painted. The home has improved on the recording of information directly relating to the daily activities and choices of residents, both staff, visitors and the manager commented that the residents are leading fuller lives and are experiencing many new activities. 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 Care Standards regulations. Similarly if regulation 26 reports were forwarded to the Commission for Social Care Inspection and are completed fully and legibly the Commission for Social Care Inspection would have a clearer view of the dayto-day management and running of the home Residents and staff would be better protected from potential burns if the pipe work in the kitchen, connected to the boiler was covered.
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 7 In order to meet legislative requirements and demonstrate duty of care the home must inform the Commission for Social Care Inspection of incidents that affect the well being of residents. 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. Service users would be accommodated in a well maintained environment and the Trust would demonstrate that they are committed to providing a well maintained environment if they ensure that the ceilings and walls in the ground floor corridor are repainted to remove water ceiling stains. 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 D56 D05 YA AV S3400 Byways V217282 050505 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 Byways D56 D05 YA AV S3400 Byways V217282 050505 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, 2, 3, 4, 5. Information is available to residents and their representatives about the home and the admission processes provide adequate safeguards for all. EVIDENCE: Since the last inspection the home has evaluated and updated the homes statement of purpose to contain full information of the services and facilities that are provided at Byways. There are currently no vacancies at the home and there have not been for some time, however the manager was able to provide clear details of how any future admissions to the home would take place, she explained that the home has an admissions procedure contained within the statement of purpose and said that admissions would be tailored to the needs of the individual and would be taken at their pace. Also in place were care management assessments and the homes own assessment which is completed during the trial period. The manager said that the needs and views of those already living at the home would also be considered as part of the assessment and decision making process. All of the residents are provided with a written and costed copy of the terms and conditions of the placement, the manager said that key workers spend time with individuals explaining the contents of these documents and the significance of it for residents.
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 10 Comprehensive care management and health need assessments were seen on file. The home has developed comprehensive care plans from the information provided by the resident’s and information gathered during the assessment process and during the trial period. The home has introduced daily diaries for residents, these record the personal choices that individuals have made, individuals preferred routines and staff support which promote the rights and wishes of residents. Byways D56 D05 YA AV S3400 Byways V217282 050505 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) 6,7,8,9,10 Social activities and community presence are well managed, and are tailored to the specific wishes and abilities of the individuals, these were well managed, creative and provide daily variation and interest for the people living in the home. EVIDENCE: Each individual had in place information in order to inform staff of resident’s assessed needs. Recorded were their expressed wishes and individual’s personal goals, objectives and action they were seen in order to meet these. Plans are reviewed on a regular basis to ensure that plans are successful and meet individuals current and changing needs. The home has developed comprehensive risk assessments which have been produced within a risk management framework, without impacting on individual’s expressed choices; assessments seen, included, manual handling, accessing community facilities, health, individuals wellbeing and medical conditions. Each resident had in place clear communication strategies in order to direct staff to the most effective methods for individuals. Each document had been reviewed and it was clearly evident that these are working documents which
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 12 are amended and added to when a specific area of communication is established. Personal care statements were in place for resident’s and outlined the wishes of individual’s and provided clear guidance on how they wanted to be supported with aspects of their personal care. Resident’s and staff records are kept in an office that is able to be locked when not in use. Byways D56 D05 YA AV S3400 Byways V217282 050505 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, 15, 16 Links with the community are good, these support and enrich individuals social, educational and personal development. EVIDENCE: Information seen by the inspector, and confirmed by staff and day care support workers showed that those living at the home are offered a variety of social activities. Resident’s are able to participate or not, this is dependent on the individual’s choice. At the time of the inspection residents were participating in a number of activities of their choosing, these included being supported on a one to one basis to go swimming, attending bingo and visiting friends at social clubs. Each resident had in place a weekly plan; recording the activities they have chosen to participate in, these plans were enhanced by the use of pictures and symbols and it was evident that individuals had played an active part in the decision making process.
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 14 Each resident has in place an essential lifestyle folder which outlines the expressed wishes, routines, likes, dislikes and choices of individuals and how staff work with individuals in order to respect these and work in a person centred way. Tracy Wetherald is a facilitator for person centred workshops and came across during the inspection as very committed to empowering individuals to lead a fulfilled life of their choosing. One of the resident’s at the home is currently being supported by the staff team in order to explore the possibilities of living in a more independent way, the individual made this decision during a three day person centred workshop and options for this person are being explored. A day care support worker at the home told the inspector of the relationship they had developed with one of the residents, one that was built on mutual trust and understanding and had been established over a long period of time. Information seen in daily diaries evidenced that resident’s regularly take part in the following activities: aromatherapy, attendance at college, cooking, gardening, religious worship and visiting family and friends. Staff members spoke with great pleasure when recently supporting two resident’s on their recent holiday to Holland. Byways D56 D05 YA AV S3400 Byways V217282 050505 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, 20 Residents are supported in their preferred manner and individual’s physical, emotional, healthcare and medication needs are well met. EVIDENCE: All of the residents are registered with a general practitioner. The manager told the inspector that individuals are supported by their key workers in order to visit the doctor and to attend healthcare appointments. Care plans were in place to support individual’s health with clear strategies in place in order to direct and guide staff. Medication was seen being administered in a safe manner and records had been completed correctly. Medication is stored in a locked trolley. At the time of the inspection one of the staff members was undertaking some medication competency training and provided the inspector with clear information of what they had been taught, their role, responsibility and accountability in this area. There was evidence in the home to show that individual’s medication is monitored by a psychologist and in consultation with the general practitioner, is amended when required. Information on care records showed that
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 16 individual’s changing physical and healthcare needs are monitored and prompt appropriate attention is sought to ensure that individuals are supported appropriately. Clear examples of these include ophthalmic, dementia and epilepsy support. Byways D56 D05 YA AV S3400 Byways V217282 050505 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 The home has a satisfactory complaints system in place with some evidence that resident’s feel their views are listened to or acted upon. EVIDENCE: Each of the residents had in place a written copy of the organisation’s complaints procedure, these documents had pictures and photographs and had been written in plain language. The inspector viewed the complaints logbook; there were no recorded entries, the manager explained that residents are supported to express their views and any areas of concern they may have would be interpreted by staff on a daily basis. Due to the nature of individuals learning disabilities there are people living at the home who may not be able to verbalise a complaint, the manager said that any changes in individual’s behaviour, actions and voice tone are recorded and appropriate support would be given to the individuals. Staff have signed to say they have an awareness of the organisation’s complaints procedure and their responsibility in this area in order to support individuals and to facilitate any complaint and to also ensure that individuals are given the opportunity to raise any concerns. Policies and procedures are in place to minimise the risk to resident’s from any form of abuse. A staff member told the inspector of the comprehensive knowledge of the protection of vulnerable adults training that they had undertaken as part of their National Vocational Qualification and how this provided additional insight into their role and responsibilities. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 18 No complaints have been received by either the home or the Commission for Social Care Inspection. No resident’s at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation During the inspection two staff were observed auditing individual’s personal monies held for safekeeping by the home, this is done on a daily basis and records for this were seen to be well maintained. Financial systems are audited by external auditors on an annual basis. The home failed to report an incident that affected the wellbeing of those living at the home; these must be reported to the Commission for Social Care Inspection, and therefore the home did not demonstrate clear accountability within it’s duty of care in this instance. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 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 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, arrangements must be made to ensure that areas of the home are well maintained. EVIDENCE: The home is well furnished and maintained to a standard that creates a comfortable ambience. Two ceilings on the ground floor have been re-painted since the last inspection, however there is some water stains 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. Locks are provided on toilet and bathroom areas ensuring that these areas are able to be locked to ensure residents privacy. The home was found to be clean, tidy and odour free at the time of the inspection.
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 20 Communal areas of the home provide a homely area for residents to relax and undertake social activities of their choosing and to entertain guests. The home has a large pleasant garden for resident’s user to enjoy, grow plants and vegetables. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34,35, 36 The relationships between staff and residents are good, creating a warm, supportive environment in which the resident’s quality of life is improved. EVIDENCE: All staff records were examined and although some progress had been made to hold staff recruitment documents on the premises it was evident that all of the documents as outlined within schedule two were not in place, therefore the requirement made at the previous inspection has not been met and will be further reviewed at the next inspection. Staff spoke positively about the training they had received and how this has had a positive influence on them within their role. A staff member who is currently undertaking a National Vocational Qualification at Level 3, promoting independence told how they have grown in confidence and have broadened their knowledge, they gave recent examples of how they have used skills in order to influence others and to promote the rights of people with a learning disability. Tracy Wetherald told the inspector about the robust recruitment and selection process that has recently taken place in order to recruit support workers; the process was undertaken in accordance with the organisational policies and
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 22 procedures such as equal opportunities. The manager told the inspector of the process in which residents are actively involved in the interview process, their feedback provides some influence in the decision making process. Two recently appointed staff members told the inspector about their induction process and gave clear examples of how they have been supported by the organisation, the manager and members of the staff team in order that they are provided with clear information and guidance of the expectations on them in order to fulfil their role, both have been allocated places on core training such as fire safety, manual handling and values training. At the time of the inspection one of the new staff members was undertaking medication competency training. Staff spoken with told the inspector that they receive formal, structured supervision sessions that focus on their role and responsibilities as both support and key worker, they said that sessions take place on a one to one basis and areas of personal development are also evaluated and action plans set. Supervision records were not examined at this inspection, these have been viewed at previous inspections. Minutes of team meetings were viewed, these take place on a regular basis and provide a forum for staff to air their views, exchange ideas and set future team goals in order to provide a good service for those living at Byways. The inspector saw information about a team ‘Pathway’; staff told the inspector that this process had been well structured and enabled the team to evaluate their current service provision, to undertake a full audit of what the home does well and identified areas of improvement in order to plan ahead and monitor service delivery. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 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 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) 37,38, 39, 40, 41, 42, 43. The home is well managed ensuring that resident interests and rights are promoted and protected by a knowledgeable and experienced staff team within a environment that on the whole is a safe one. EVIDENCE: Tracy Wetherald is qualified as an RNMH (Registered Nurse Mental Handicap), and has considerable experience in both hospital and community care settings. She has been employed by the Trust for 17 years. Ms Wetherald has been employed at Byways as a Home Manager for over eighteen months and is well aware of her responsibilities for this position. During this time, the manager has undertaken a range of management and care related training sessions and courses to support her role in the home. Ms Wetherald has been an active member of a number of working groups in order to improve and influence service provision, these include action learning sets, provding support for managers and developing effective risk assessments for residents holidays. Ms Wetherald has recently attended a conference about
Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 24 supported living; this was a useful source of information in relation to the needs of a current resident at Byways. Ms Wetherald has attained her D32/33 qualification to assess NVQ training of support workers in the home and has completed National Vocational Qualification level 4 in care management. The atmosphere at the home at the time of the inspection was calm and relaxed with residents looking clearly at ease and ‘at home’. Positive comments were made to the inspector by visitors and staff spoken with at the home, comments made were that ‘the home is well managed’, ‘residents are happy’ and ‘services are tailored to individuals needs’ and ‘that the manager listens to suggestions and ideas and is approachable’. The home have developed effective methods of monitoring the frequency of weekly and monthly fire safety checks and initiated a system for the monitoring of staff training. A fire lecture to take place at the home had been arranged for 7th May 2005. 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 are updated in order to reflect the status of the Trust. An effective quality assurance audit has been developed within the home, the inspector saw how one to one time spent with individuals has been used in order that the feedback received has directly influenced the quality of life for the resident and had a positive effect on service delivery. The home also monitors the effectiveness of service provision and staff knowledge and understanding through team days, team meetings, peer support, staff induction, training and supervision. Staff were able to demonstrate a clear understanding of their roles and responsibilities and how they work in a person centred manner, tailored to the individuals needs of those living at Byways. At the inspection undertaken in December 2004 a requirement was made that records of visits on behalf of the registered provider must be forwarded to the Commission for Social care Inspection as previous reports had not been received since September 2003, following a meeting held with Linda Phelps, the service manager, and the registered manager held in December 2004 reports were forwarded, however no further reports have been received. There has been a new water heater fitted in the kitchen, the pipes were unguarded and were hot to the touch, it is required that these pipes are covered in order to prevent potential burns to both resident’s and staff. Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Byways Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 2 D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 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. Standard YA 41 Regulation 37 Requirement The Commission are to be notified in writing of any incident which may affect the well-being of individuals at the home. All staff recruitment documentation to be held at the home and be available by the CSCI at all times. Hot water pipes to be covered. Ensure that copies of the monthly visits undertaken by a representative of the is forwarded to the CSCI. Timescale for action 06/05/05 2. YA 34 19(b) 06/06/05 3. 4. YA 42 YA 39 23 26 06/06/05 06/06/05 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. 2. Refer to Standard YA 24 YA 40 Good Practice Recommendations Water stains on ceiling in coridoor to be re painited. Headings on polices and proceedures to be changed in order to reflect current status Byways D56 D05 YA AV S3400 Byways V217282 050505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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
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