Inspection on 16/11/05 for Coronation Road, 63

This inspection was carried out on 16th November 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coronation Road, 63 02/12/08

Coronation Road, 63 05/12/06

Coronation Road, 63 23/05/05

Coronation Road, 63 19/01/05

Coronation Road, 63 16/08/04

Coronation Road, 63 25/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Coronation Road, 63 Southville Bristol BS3 1AR Lead Inspector Nicky Grayburn Unannounced Inspection 16th November 2005 09:30 Coronation Road, 63 DS0000026645.V263702.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 Coronation Road, 63 DS0000026645.V263702.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. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Coronation Road, 63 Address Southville Bristol BS3 1AR 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) 0117 9077217 0117 9709301 Aspects and Milestones Trust Miss Michelle Myra Clarke Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 35 years and over Date of last inspection 23rd May 2005 Brief Description of the Service: 63, Coronation Road is operated by Aspects and Milestones, which is a voluntary organisation. It is registered to provide personal care and accommodation for up to six people who are thirty-five and over and who have mental health needs. It is a settled household that would suit those who prefer a quiet and calm lifestyle. The home aims to encourage residents to live independent and fulfilling lives within a community setting. It is a four storey Victorian house overlooking the river, which blends in well with local surroundings. It is close to Bedminster shopping centre, major bus routes and local amenities. It benefits from a large front garden and smaller porch area to the rear. Coronation Road, 63 DS0000026645.V263702.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, the purpose of which was to ensure that the home is continuing with compliance with legislation and the National Minimum Standards. Evidence for the report was gathered from documentation such as three care files; four staff files; health and safety documentation; and policies and procedures. The inspector also spent time talking to the service users and some members of the staff team. The inspector toured the premises and was invited to view two service user’s bedrooms. What the service does well: 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. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 6 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 Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 7 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): 2, 4, 5 Service user’s needs are assessed and they have the opportunity to test-drive the home prior to moving in to ensure that the home can meet their needs and that they like the home. Service users are informed of changes regarding the terms and conditions of their residency at the home. EVIDENCE: There have been no admissions since the last inspection. The three care files looked at all had a core assessment carried out by a social worker or qualified assessor with the service user’s psychiatrist present. This ensured that their needs were assessed and the home could meet them, before permanent residency was undertaken. The revised admissions policy and procedure insists that potential service users visit the home at least three times, with at least one overnight stay. As noted from the previous inspection, the home’s brochure needs to be updated. The manager is yet to do this. It has not been a priority as there are no foreseeable vacancies. The brochure will contain photos, inclusive of the recently completed kitchen. It is recommended that the manager complete the brochure for any future changes in service users and also for the present service users. The most recent inspection report was on display on the notice board enabling access to it at any point by service users or visitors to the home. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 8 There were up-to-date Tenancy Agreement contracts, which include the service user’s weekly contribution amount, insurance for personal belongings and the house rules. Both the manager and the service user had signed these. Within some of the contracts there was no specific date to indicate the start date of the contract, but had 2005-2006 noted on the front. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 9 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, 10 Individual plans are clear and well-maintained assuring service users that any changing needs are documented and acted upon. Service users are consulted on aspects of the home and are encouraged to make their own decisions about their lives. Comprehensive risk assessments ensure that service users’ safety and well-being is promoted and safeguarded at all times. EVIDENCE: Service users have individual files, which were up-to-date and well maintained. They hold contain lots of information regarding the service user, which enables staff to deliver a person centred service. There are daily entries under the different care plans to monitor the specified areas. Each care plan is evidently regularly reviewed; the last review during July and August 2005. Within Aspects and Milestones, there is a specific ‘Service User Participation Worker’; Rosanne Levene, who helps residents to become more involved in the home and in making decisions. Her mobile number is available to service users on the notice board. She is also assisting the manager to encourage an increased participation to develop and monitor the home (refer to standard 39). Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 10 It was evident from records kept, observations in the home, and speaking with service users that they are consulted upon decision making in the home. Documentation regarding their care and life at the home had been signed by the service user. There are weekly meetings to discuss the forthcoming weekly menu, and monthly meetings to discuss broader issues such as Bonfire night and Christmas. Risk assessments were in place within care files and within the health and safety folder covering all aspects of their care in and outside of the home, such as maximising daily activities; diet; personal hygiene; using the vacuum and maintaining good health. Many of the service users are independent in terms of accessing the community. Further, the assessments are regularly reviewed (February then October 2005). In each of the individual files, there was a statement clearly stating the consent for professionals to read personal files on a need-to-know basis. The service user had signed these. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15, 16, 17 Service users are supported to undertake an independent lifestyle with appropriate opportunities for personal development and activities. Service users benefit from a healthy diet. EVIDENCE: Each service user has a dedicated ‘life skills’ day when they undertake independent living skills such as shopping, laundry, and domestic duties. Spiritual needs are stated within the personal profiles and are duly supported. In a service user’s bedroom there was a certificate of completion of a cookery course at a local college. The service user now bakes for the home and assists with the cooking of the meals. It was evident from speaking with the service users and seeing their bedrooms that they are encouraged to maintain hobbies and interests such as playing the guitar; using computers and can keep pets in their rooms. From the weekly schedules and the service users individual plans, it was apparent that support is offered and given to pursue leisure interests. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 12 Due to the varying levels of independence, some service users need a more detailed routine than others. A service user told the inspector about his football hobby and work at the City Farm which he enjoys. Service users enjoyed their holiday this year to Butlins. One service user particularly wanted to go to Normandy, which was arranged. There was evidence that other outings are arranged and that going to the theatre is a regular activity. One service user showed the inspector the photos from a recent trip to London he took with a staff member, and staff confirmed that service users are offered a great deal of activities. Family details are stated in the individual files and some service users regularly visit relatives at weekends. There is a notice in the hallway welcoming visitors and relatives. It states that there is no set visiting time but would request that the latest time be 11pm, to support the residents’ routine. Some of the service users have specific daily routines enabling them to increase their independence and to maximise their activities according to their care plan. It was observed how some service users have keys to their bedrooms, which maintains their right to privacy. Whilst at the home, the inspector observed all the staff positively interacting with service users. It was evident that there are solid relationships within the home. It was observed how service users have access to all areas of the home and can access the kitchen to make beverages and snacks at any time. Due to the size of the home, service users can choose when to be in company or spend time alone. The home is already preparing for Christmas with a list of foods to buy for the period on the notice board. The list was discussed with residents and they can add items to the list if they think of anything. Every Sunday there is a meeting to organise the forthcoming week’s dinner menu. Each service user has a particular night for their choice, with discussion, and Sundays they have roast dinner. It was observed that breakfast and lunches are eaten at a time suitable to service users. Individual profiles describe the service user’s appetite and any food preferences. A chart within the individual files showed that service user’s weight is monitored to ensure that areas of care plans are adhered to. One service user, who has a particular dietary care plan, has been steadily losing weight. The fridge and freezer was well stocked, and there was fresh fruit and vegetables. One service user is trying to decrease the cholesterol intake so staff are supporting this with alternatives to the chosen meals. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 13 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 Service users receive personal support in the way they prefer and require due to the comprehensive care plans and individual plans, which also ensure that service user’s health needs are met. The wishes of residents regarding death have been recorded respectfully and sensitively. EVIDENCE: Individual files are written so that the service user receives the care they need in a way they require. This was also observed throughout the day during the inspection. Service users got up when they wanted and it was confirmed that they could go to bed when they chose. There are care plans in place for those service users who need support regarding their personal hygiene; such as prompting to shower and encouragement with oral care. For some service users, personal care needs are incorporated within their daily schedules. Regular appointments for health professionals such as the dentist and optician are recorded in the service user’s files. The home has a visiting optician, which assesses all the service users. Appointment dates are highlighted in the diary, which are then ticked off when attended to aid communications. On the day of inspection, an extra member of staff had come in especially early to accompany a service user to the doctor. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 14 Some of the service users need regular GP appointments due to medication needs which are fully maintained. Comprehensive care plans are in place with relevant emergency and monitoring service phone numbers due to certain side effects. Changes within the care plans are noted and dated. Three service users self-medicate and the manager, and one service user, confirmed that they had medication storage space provided. Risk assessments and consent forms for administrations of medications are in place to safeguard the service users. The medication folder was examined and the necessary documentation was very well maintained. There was a signatory list of the staff team with photos identifying the service users. Each service user had a profile inclusive of side effects and medical history. These were reviewed ensuring currency of information in November 2005. All Medication Administration Records (MAR) sheets were complete. Monthly treatments were also recorded. A separate form to monitor ‘as and when’ (PRN) medication recorded the treatment; reason for the need; and had a flowing stock check. Records of any transfers of medications i.e. for holiday were also seen. Local polices i.e. ‘In the event of error’ and ‘Protocol for handling and administration of medication’ corresponded with the global policy from Milestones. Any correspondence about service users is stored in the individual files. Staff have had training from Boots in the used Monitored Dosage System (MDS) and the manager carries out ‘medication competency’ assessments. The files examined had signed comprehensive details of the wishes of the service users in the event of death. One stated that they do not want to discuss it, and if it should happen, their parents will decide. One had well thought-out details with specifics stated on the sheet. Care plans would reflect any changes in needs regarding the ageing process. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 15 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 Service users are protected from abuse and neglect. EVIDENCE: Within the Operational Information from Aspects and Milestones there is a revised complaints procedure (June 2005) stating the 28 days response time. The local policy needs updating with the current Commission for Social Care Inspection’s contact details. There is the Bristol City Council’s ‘No Secrets’ document on the staff’s notice board. In the dining room there is also a list of people’s names and job titles with their contact details for the access of service users. There no recorded complaints within the complaints book. There are monthly house meetings, which are planned and have accompanying minutes. These meetings allow service users to raise any issues. From discussion with service users, all stated that they very happy living at the home and had no complaints or concerns. When asked, the service users said that they would talk to their key worker or the manager if they did have any complaints. Staff files contained confirmation letters from head office stating that they had received the enhanced criminal records bureau check, inclusive of Protection of Vulnerable Adults check and that they were fit to work. Aspects and Milestones provide a variety of training courses ensuring that staff are fully aware of what constitutes abuse and neglect. There was evidence that staff have undertaken training in ‘Values’; ‘Vulnerable Adults Alerter’; and ‘Dealing with Difficult Complaints’. It was clear that staff would have no difficulty in reporting any concerns to the manager or the CSCI. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Service users enjoy a comfortable and homely environment, which is clean and hygienic. The home is a safe environment. EVIDENCE: The home is a large property, which blends in with the surrounding neighbourhood. Rooms are located over the four floors and all are decorated in a homely style. The home was warm and cosy throughout the day. The main garden is at the front of the house with a small seating area and parking at the rear. The kitchen has been well refurbished and redecorated and staff and service users said that it has greatly improved as they were in need of a new kitchen. Two bedrooms were entered with the service user and both were very clean and personalised. Service users are responsible for cleaning their own rooms. One service user told the inspector how they were able to choose the colours and décor. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 17 Two service users had recently swapped rooms, which reduces the risk of trips and falls, and allows greater independent mobility. Staff, and the service user, confirmed that all parties agreed to the move and are much happier in their rooms. The recommendation of replacing a carpet had been replaced during the move and redecoration. There are sufficient toilet and washing facilities within the property, all of which have lockable doors ensuring privacy. One of the bathrooms has small grab rails to enable service users to bathe as independently as possible. There are two lounges both with comfortable homely furnishings and televisions, one of which is the smoking room. There is a third television in the dining area, as one service user particularly likes spending time there. The manager has already budgeted for a new carpet in one of the lounges, which would be recommended to replace in the future. There has been one more strobe light fitted in the lounge within the fire alarm system to maximise service users safety. The home was entirely clean. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 18 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 Service users benefit from having a stable and well trained staff team. Regular supervisions ensure that staff receive the support required to care for the service users. EVIDENCE: Four of the five staff personal files were examined and are well maintained and organised. The inspector saw a copy of the job description and key worker’s responsibilities and it was evident that staff knew their role within the home. The staff team have been stable for a number of years with one new member of staff starting at the beginning of the year. Some of the paperwork has been kept at head office. The manager is to obtain the missing paperwork. Four members of staff have their National Vocational Qualification (NVQ) in care, and one has the City and Guilds Certificate in Community Mental Health. Staff confirmed that Aspects and Milestones are very good at providing training opportunities. Training records are kept on file exceeding the statutory requirements, such as ‘Assertiveness’; ‘Introduction to Challenging Behaviour; ‘Introduction to Person Centred Planning’; and ‘Risk Assessment Workshop’. All five members of staff have recently undertaken fire safety training and four staff members are Appointed Persons for First Aid. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 19 Each member of staff has a personal development plan and have received annual appraisals. Evidence of frequent, and meaningful supervisions were present in all files, exceeding the minimum requirements. There are also regular staff meetings, with one occurring on the day of the inspection. Staff members confirmed that there is good morale within the team and all work together very well. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 20 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 The registered manager demonstrates good leadership and management skills. Service users are assured that they are safeguarded by the home’s policies and procedures and well-organised record keeping. The health, safety and welfare of the service users is promoted. Consultation with service users, relatives and visitors would further benefit the home and service users. EVIDENCE: The manager of the home was present on the day of the inspection and has worked at the home since 2001. She undertakes relevant training to update her knowledge such as ‘Managing sickness/absence’; ‘Devising in-house policies’; and ‘Problem solving and Decision Making’. She is also an NVQ Assessor. Service users told the inspector that they would approach the manager with any concerns and that ‘she is very nice’. It was evident through discussion that the manager has very good management skills and is a confident leader. The home had a very open and inclusive atmosphere, which enables service users to feel at home and the staff to work in a positive manner. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 21 The quality assurance system is under development with assistance from the Service User Participation Worker; Rosanne Levene. The policy regarding this states that a full audit is due on an annual basis. The home does support service users to voice their opinion and the CSCI receives monthly Regulation 26 reports ensuring that an overview of the home is obtained. A comprehensive plan for the home is required to ensure that all views from service users, visitors and relatives and any external professionals are gained in order to develop the home in the best interests of the service users. Staff and service users have access to a full set of operational policies and procedures from Aspects and Milestones, which were re-issued in June 2005. The manager and numerous staff members have signed these to confirm that they have read the documentation. There are also local in-house policies for more specific information such as fireworks policy and risk assessment, accidents and incidents, and medication policy. All documentation kept at the home is in very good order and is well maintained. Key documents are kept safe in locked cabinets. There is also a specific Health and Safety folder with policies such as ‘Control of Legionella’ and ‘Control of Infection’ dated 1/5/5 so that staff are aware of the issues that could arise from poor hygiene or low water temperatures. This further protects the service users. The fire logbook indicated that the relevant checks and tests for detection and protection from fire are carried out within the appropriate intervals. The most recent fire drill was 1/9/5 and it was noted how one resident needs to be informed and supported throughout the drill. Certain staff have areas of responsibilities such as COSHH and Food Hygiene. The generic fire risk assessment and local policy had been reviewed on 3/10/5. The gas meter has been replaced and an inspection was carried out on 3/8/5 and the property was found to be satisfactory. Avon Fire and Rescue Inspection deemed the home ‘satisfactory’ on 18/10/05. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 22 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 X 3 X 3 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 4 3 2 3 4 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Coronation Road, 63 Score 3 3 4 3 Standard No 37 38 39 40 41 42 43 Score 3 4 2 3 3 3 X DS0000026645.V263702.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard YA22 YA34 YA39 Regulation 5(1)(e,f) 22(7)(a) Sch 2 24 Requirement Complaints policy to be updated with current CSCI details. References and contracts are to be kept on individual personnel files. A quality assurance system to be implemented. Timescale for action 31/12/05 31/12/05 31/01/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The home’s brochure / Service User Guide is completed. Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 24 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 Coronation Road, 63 DS0000026645.V263702.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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