Inspection on 16/02/07 for Clevedon House

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Clevedon House 15/03/06

Clevedon House 25/08/05

Clevedon House 03/02/05

Clevedon House 27/07/04

Clevedon House 18/09/03

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 Clevedon House 70 Clevedon Road Weston Super Mare North Somerset BS23 1DF Lead Inspector Catherine Hill Key Unannounced Inspection 16th February 2007 10:50 Clevedon House DS0000008083.V319338.R02.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 Clevedon House DS0000008083.V319338.R02.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. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clevedon House Address 70 Clevedon Road Weston Super Mare North Somerset BS23 1DF 01934 624836 01934 624836 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) Freeways Trust Limited Miss Shelley Ann Holvey Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2006 Brief Description of the Service: Clevedon House is part of the Freeways Trust and is a community home for people with a learning disability. It is situated in a quiet residential area of Weston-super-Mare, close to local amenities, the seafront and the town centre. The home is two converted semi-detached Victorian houses. Most of the residents are in their forties or fifties, although a couple of people are over retirement age. The current range of fees is £386.35 to £768. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was comprised of a pre-inspection survey of health-and social care professionals associated with the home, and a one-day unannounced visit to the home. The inspector also met with some service users at their day centre last year. The manager submitted some information prior to this inspection in the form of a pre-inspection questionnaire. Freeways Trust sends the inspector a copy of their own monthly unannounced quality monitoring visits, which also provided the basis for some of the checks carried out during the visit. Two of the professionals surveyed responded. One person commented that the present manager has been very effective in improving the quality of care within this home. The other said that they have always been made to feel very welcome ... The manager ... is very approachable. I feel we really are working in partnership. One professional noted that any concerns are reported swiftly and dealt with appropriately by the home. During the visit to the home, the inspectors spoke with nine of the residents and with most of the staff on duty. Most of these conversations were private and in-depth, but some were less in-depth and took place in communal areas. One of the residents gave the inspector a tour of the communal areas, and of her own room. The inspector also looked at some records, including: • residents care records • the Service Users Guide • records relating to the person most recently admitted to the home • residents contracts and statements of terms and conditions • residents timetables • medications records • the complaints file • the maintenance log • health and safety checks • records relating to staff recruitment, training and supervision. What the service does well: The staff team has worked really hard on shifting the homes culture, and has made excellent progress towards providing a truly person-centred service that empowers its users to take charge of their own lives. It has been noticeable over the past few inspections how much happier both the residents and staff are, and how much freer residents feel to be themselves and say what they really think. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 6 Residents care records are exceptionally informative and thorough. They are increasingly reflecting the persons own views and wishes. The support that staff give to each resident is well planned and well documented. Interesting opportunities have been identified and arranged for each resident’s work and leisure time. People are leading full and varied lives, with plenty of opportunities to develop and to move on. Staff selection is thorough and careful. Freeways Trust provides an excellent range of training opportunities, and the manager and her deputy support the team with frequent one-to-one supervision sessions. Senior managers from the Trust are readily accessible and frequently visit the home unannounced, spending a lot of time talking to the residents and staff. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Clevedon House DS0000008083.V319338.R02.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 Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents get plenty of written information about what they can expect from the service. The home gathers a good level of information on prospective residents to ensure that it will be able to offer the right service. Admission procedures are flexible. EVIDENCE: The Statement of Purpose is kept under regular review. The Service Users Guide is in a user-friendly format and has lots of photographs and pictures. The most recent resident had a copy of this on his file, which was signed by him and the two staff members who had talked through the document with him soon after he moved in. Staff also go through a detailed introduction checklist with new residents, so that each person is clear about issues such as confidentiality, the sort of information that will be kept on them, who the staff are and when they will be working, what their rights are, and who the other people are that share the home with them. Staff also show the person how to use the homes facilities, such as the television, kitchen and laundry equipment. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 9 The home’s emergency admissions procedure has been amended to more clearly show that it is the registered manager who makes the decision about new admissions. The file of the most recently admitted person was checked. This included detailed information gathered on their needs before they moved in. Trial periods are flexibly planned to suit individual needs. The residents files sampled included service user agreements in straightforward English, supported by pictures. These clearly showed the amounts of contributions towards each element of the service. The resident and a member of staff who went through the document with them had both signed it. Information on services and charges not covered by the fee was equally clear. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents needs and preferences are exceptionally well documented. The service is flexible and involves other carers appropriately to ensure that needs are well met. Residents are now being much more involved in all aspects of the homes and wider organizations life. EVIDENCE: The care plans seen gave clear information on what each person hopes to achieve and the support they need from staff to do this. There are phrased positively, emphasising what the person is able to do and what they need support with, rather than focusing on what they cannot do. Care plans are broken down into different areas such as physical health, mobility, daily living, psychological and emotional well-being, social and leisure interests, personal safety and risks, and vocational and educational occupation. Care plans are reviewed at least every six months. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 11 Some of the care plans seen included detailed breakdowns of the small steps to be taken towards meeting a larger goal. Some of the residents who talked to the inspector about the support they get confirmed that they are helped to achieve their goals this way. Several entries are made on each persons care notes every day, and these combined to provide a really clear picture of the sort of activities people are able to participate in, any changes in mood or any significant events in the persons life, any new needs that arise, and what is being done to support the person. Key workers do a monthly report which summarizes progress and checks that routine health care appointments have been kept. A new format is in place for the key worker monthly reports for those residents who are over the age of 65. This prompts a more detailed review of physical health, personal care, appetite, mobility, and other issues that might affect older people more. Key worker reports end with a list of actions to be completed in the following month. These reports were clearly cross-referenced to other documents used in planning and monitoring the persons care. The way the service is pitched has changed gradually but dramatically over the past couple of years. The staff team has steadily moved away from a culture in which staff ran the home, towards a culture in which residents run their own lives with support from staff. The manager and staff said that there has been a lot more training and informal discussion over the past year or so on residents rights and how to adopt a person-centred approach. Comments made by residents and staff during this inspection revealed how successfully the team has adapted its practice. Residents described a generally much more adult-to-adult approach by the staff team, and their demeanour showed that they feel much more empowered in their own home. The way staff interacted with residents had also noticeably shifted: the tone of voice and the subjects of conversation were much more as one adult to another. Written risk assessments are on file, and these show that risks are clearly identified but that ways are sort of managing these without unduly restricting the person. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each person is offered an excellent range of opportunities for personal development and meaningful occupation. The homes culture has been gradually shifting and now more fully recognizes residents rights and responsibilities. EVIDENCE: Each person has a full and interesting individual timetable of activities. Some of the older residents who have retired no longer have vocational pastimes, Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 13 but each person gets regular one-to-one time with staff and plenty of opportunities to join in social and leisure activities. Each person has an activities day once a week, which includes some one-to-one time with staff and some small-group time. These days are used to carry out personal chores with support and to pursue particular interests, within the home and as part of the wider community. One person has paid employment with a contract and job description within the home. Another person who was employed within the home has now moved on to external employment. Some people have voluntary jobs outside the home, and some attend college courses and day centres. One person is currently interviewing for paid employment outside the home. Residents enthusiastically described their work and leisure lives. Peoples opportunities have really broadened. It was a pleasure to see how some people have grown in poise and confidence over the past year. The residents noticeboard contained lots of information on community events, along with other documents such as a user-friendly copy of the complaints procedure, and a copy of the home’s Ground Rules agreed by the residents. A user-friendly version of the staff rota is posted nearby. The activities days timetable is in a similar format to the staff rota so that residents can more easily see when their activities day is scheduled and who with. Residents meetings are held regularly, and recent minutes are displayed on the noticeboard in the dining room. An agenda form is also put on this noticeboard so that people can add any issues they would like to raise at the next meeting. More recent meetings minutes show that residents are increasingly raising issues for discussion and contributing ideas. Information that might be of interest to the residents is also brought to their attention at these meetings: staff are raising the Fulfilling Lives project with the residents, which is being run by the Learning Disabilities Partnership Board. Each meeting now starts by looking back at the minutes of the last meeting, and reviewing the action that has been taken to address the issues raised. This helps to ensure that problems and suggestions are properly followed up and are not lost. Minutes showed that residents suggestions are acted upon, which may go a long way towards encouraging people to keep coming up with ideas. Menus are regularly raised for discussion at these meetings. Residents were asked about their ideas for the Christmas menu at one meeting, then the provisional Christmas menu was shown to them at the next meeting, and people were asked for feedback on this after Christmas. Residents have also been asked to suggest theme evenings, and each person is asked what they would like to do to celebrate their birthdays. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 14 Residents said that they are much more involved with cooking and kitchen chores now. While the evening meals tend to be planned some way in advance by the whole group, lunches are a more flexible meal, and people are offered several choices there and then. Clevedon House DS0000008083.V319338.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each persons preferences for how they receive support are well documented and are respected. Needs are documented in some depth but Health Action Plans should be expanded to cover more routine health checks. EVIDENCE: A Health Action Plan is now in place for each resident. These are in a userfriendly format and are kept under regular review. They were phrased very much from the point of view of the person to whom they belonged, and included clear information on how they like support to be given. The Health Action Plans sampled addressed a broad range of issues specific to the individuals health needs. However, they should be expanded to include routine health checks such as cervical smears, breast checks, Well Man clinics, etc. External advice has been sought appropriately as individual residents health needs change. One person is now having difficulty using the minibus, so taxis Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 16 are being provided while the home awaits the arrival of a new minibus with a tail lift. Medications records are clear and thorough. Each resident has an individual section within the file. Each section has a front sheet with the persons photo, basic details, and there timetable of activities so that staff can ensure they have medications at the right times wherever they are. Each persons medications are checked at every shift hand over. Medications Administration Record Sheets are clear and up-to-date. Medications received in the home are also recorded on these sheets. There were a number of reported medication errors around the time of the last inspection, but no further incidents have been reported for some time. The improved medication system seems to be greatly helping staff to administer medications accurately. One person is learning to become more responsible for their own medication, and it is planned but other residents will be starting their own programs in the near future. Lockable medication cabinets have been installed in several peoples bedrooms in readiness. A well thought out, step-by-step learning programme has been drawn up for the first resident. Clevedon House DS0000008083.V319338.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents views and rights are respected. Complaints are responded to positively. EVIDENCE: There is a welcoming and informative complaints procedure, and a pictorial version is available for residents. Those residents files sampled included a copy of this, which had been recently re-issued with photographs of current managers and updated phone numbers. The complaints procedure includes a photograph of the inspector and her contact details. A lot of work has been done on complaints with the resident group over the past year or so. Residents have each been supported to complete a Listen to Me book, which logs what support the person wants and how they wish to receive it. No complaints had been received by CSCI since the last inspection. A complaints form has been brought into use, rather than a book, so that each complaint can be kept confidential if necessary. The staff team takes residents negative comments very seriously: a large number of complaints Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 18 have been recorded in the home’s complaints file, but only one of these concerned a reportable matter. The other complaints were comparatively minor issues that were easily and quickly resolved. The record of these complaints shows what actions were taken to address each issue, and what outcomes were achieved. Residents comments and the managers records show that the serious complaint was dealt with promptly and appropriately. The manager conducted a particularly thorough investigation that took all viewpoints into account and achieved a fair resolution. An external professional noted that any concerns are reported swiftly and dealt with appropriately by the home. Freeways Trust has a comprehensive adult protection procedure, in line with North Somerset Social Services No Secrets guidance. Staff receive regular abuse awareness training. Clevedon House DS0000008083.V319338.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clevedon House provides a comfortable and pleasant environment for its residents, which is well suited to their needs. EVIDENCE: The home is made up of two semi-detached houses, and blends in with the neighbouring properties. There is a pleasant dining area leading off the conservatory lounge and next to the kitchen. The French window from the conservatory leads out to the back garden. There is a smaller television lounge and an activities room just off the conservatory. The conservatory had been redecorated and recarpeted by the time of the last inspection, and has since been fitted with roof and window blinds, making it a really attractive and pleasant room. The furniture has been replaced, and new furniture has also been provided in the television lounge. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 20 A proper sleeping-in room has now been created next to the office. The second sleeping-in staff member uses a small bedroom set aside for this purpose. Many of the fire doors are fitted with magnetic door closes, so that they can close freely if the fire alarm sounds. Some adaptations and repainting have been carried out to help one resident with failing sight move around the home safely and independently. A lot of work has been done on the bathrooms over the past year, and these now provide a much better range of facilities for the residents as well as looking far more welcoming. Toilet 6, in the corridor just off the conservatory, is not currently used but is being refitted with a new toilet soon. Work has also been done on the damp problem that was affecting the top floor, and several areas have been redecorated since this work was completed. The home has just changed its system for recording maintenance problems and requesting repairs. The new system cuts down on some of the unnecessary duplication and provides a much clearer audit trail. The manager reported no significant delays on necessary repairs. New keys had been requested so that each person can be offered a key to their own bedroom. Staff carry a master key so that they can gain access in an emergency. A key storage system is being planned for people who do not wish to carry their keys with them. Clevedon House DS0000008083.V319338.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents wellbeing is promoted by effective staffing practices. Recruitment, training, and supervision practices are exceptionally thorough. EVIDENCE: Each staff role is supported by a detailed job description. Staff met during this inspection were clear about what is expected of them. Four staff were on duty on the morning of this unannounced visit. Two staff are on duty at all times as a minimum, but three staff are on duty most shifts. Up to five staff can be on duty at any one time, depending on how much oneto-one work is scheduled. Two staff sleep in at night. Staff have had a lot of training and other opportunities to get together and discuss practice issues over the past year. This has had a noticeable effect on staff members interactions with residents, and both residents and staff commented that the homes atmosphere feels happier as a result. Some staff Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 22 said that they feel like a stronger team now, and some felt that they have developed as individuals. Potential staff are required to complete an in-depth application form. Three references are sought, which is in excess of the required minimum standard. Reference requests seek a good level of information on the person. PoVA First checks are always carried out prior to the person starting work in the home, and a CRB check is carried out as rapidly as possible. These records and the copies of staff IDs are kept at Freeways Trust headquarters by agreement with CSCI. The manager submitted records of recent staff training prior to this inspection. These records, along with the staff file sampled during the visit, showed that an excellent range of interesting and relevant training is still being offered. Recent training includes LDAF (Learning Disabilities Award Framework), City and Guilds certificate, managing challenging behaviour, confidentiality, safe handling of medicines, basic food hygiene, COSHH (Control Of Substances Hazardous to Health) training, and first aid. Dementia awareness training is planned for the immediate future. The manager has drawn up a training plan for the coming year which notes statutory training requirements as well as individual staff members training needs. Three staff have recently passed NVQ 3, and two more staff hope to complete this within the next couple of months. Staff have one-to-one formal supervision with the manager or deputy every couple of months. Clevedon House DS0000008083.V319338.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home and the wider organization each have an open culture. Service users have an unusual degree of influence, both in their own home and over organization-wide issues. EVIDENCE: Shelley Holvey has been managing the home since mid-2005. She was registered as the manager early in 2006. She has experience of managing another Freeways home prior to Clevedon House and holds the Registered Managers Award. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 24 Staff had a team day recently, and regular team meetings are held. Staff feel able to contribute to the agenda for these, and felt that the homes manager and Freeways Trust senior managers listen to their point of view. Staff feel that they get clear direction and good support from the management team. Individual staff also take on responsibility for particular aspects of the running of the home, according to their interests and special skills. Each member of staff has rostered office time to allow them time to write up reports. The organisation has a strong commitment to empowering the people who use its services. Freeways Trust has paid for some residents to do NVQ 1 in cleaning, and have provided paid work experience in the home. One person has used this as a springboard to move on to external employment. Freeways has introduced picture- and symbol-supported policies to make them more accessible to residents, and a working party of service users supported by staff has been reviewing and revising a number of the organizations policies. Freeways Business Plan and Strategy has also been produced in a more accessible format for the people who use its services. Residents files sampled included a financial agreement for the current year, signed by the person themselves and by the member of staff who talked them through it. There is a well-designed system for managing residents money, which has a number of inbuilt fail-safes. The fire precautions log book shows that fire equipment checks are being done regularly and that staff are receiving refresher training. A monthly health and safety check of the environment is also carried out. Freeways has comprehensive health and safety policies and risk assessments on site. Freeways line managers visit unannounced at least every month, spend time talking with residents and staff about the quality of service provided, and produce a comprehensive written report afterwards. A senior staff member from another home also recently visited to carry out a quality audit, and interviewed several of the residents as part of this. A fire drill happened during this inspection, after a break glass was inadvertently activated. Residents and staff evacuated the building promptly and in line with the homes fire procedure. The manager praised everyone for the way they did this. Clevedon House DS0000008083.V319338.R02.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 4 2 3 3 3 4 3 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 4 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 4 4 3 4 Clevedon House DS0000008083.V319338.R02.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA19 Good Practice Recommendations Health Action Plans should be expanded to include routine health checks such as cervical smears, breast checks, Well Man clinics, etc. Clevedon House DS0000008083.V319338.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clevedon House DS0000008083.V319338.R02.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. 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