Inspection on 18/09/07 for Court View

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Court View 22/07/08

Court View 28/12/06

Court View 28/02/06

Court View 30/09/05

Court View 17/03/05

Court View 05/10/04

Court View 12/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Court View 23 Parkfield Road Pucklechurch South Glos BS16 9PN Lead Inspector Odette Coveney Key Unannounced Inspection 18th September 2007 09:00 Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Court View Address 23 Parkfield Road Pucklechurch South Glos BS16 9PN 0117 937 4021 0117 9709301 debb@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust 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) To be appointed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 5 persons aged 18 - 64 years of age Date of last inspection 28th December 2006 Brief Description of the Service: 23 Parkfield Road, Pucklechurch, known as Court View provides accommodation for five service users with learning disabilities aged between 19 and 64 years. It is one of the homes operated by the Aspects & Milestones Trust formally known as Frenchay and Southmead Care Trust. The house is a detached dormer bungalow with a large rear garden. The ample front garden is also used as parking space; there is a large, well-established garden to the rear. The accommodation consists of 5 single bedrooms, 2 bathrooms, dining room, kitchen, and lounge. The house is within walking distance of a public house and local shops. There is a bus service to the centre of Bristol and the house is within easy access of the motorway system. The mission statement of the organisation is: To enable people with learning difficulties, mental health needs and physical disabilities to develop a fulfilling life in the community and to continually seek to improve and be responsive to the changing needs and wishes of the people we support. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key standard site visit, it was carried out in one day over a 7-hour period by one inspector for the Commission who was also accompanied by an Environmental Health officer from South Gloucestershire Council who focussed on health and safety within the home. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Manager a completed annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for three individuals were reviewed. The registration certificate for the home was reviewed at this site visit. 7 comment cards were received prior to the site visit, 5 were from individual’s who live at the home, the other 2 comment cards were from visiting health/social care professionals who visit individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the Manager and have been incorporated within this inspection report. What the service does well: Courtview provides residential support to adults, some of whom have complex needs, staff work well to ensure that individuals are supported in an individualised manner with one to one support provided when required, good strategies are in place in order to direct and guide staff practice. The staff team are committed, caring and respectful at all times, this was observed throughout the inspection. Service users use the local and surrounding areas to access a variety of activities and leisure pursuits. Opportunities are provided to enable service users to access appropriate leisure and social activities. The care plans of service users are clearly written and provide clear details on how service users wish to be supported. The home responds appropriately to service users health care needs and ensures they have access to specialist health care services. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 6 There are ongoing training courses that are attended in order to enable staff to meet individual residents needs and ensure residents are protected from harm and abuse. The management at the home monitors the quality of the care and there are sound systems in place to underpin this. What has improved since the last inspection? What they could do better: In order for long term arrangements in respect of the management of the home it is required that arrangements are made for a permanent registered manager to be in post. It is further recommended, to aid communication for Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 7 service users that a photograph of the manager be added to the staff photo board. In order to ensure that service users monies are kept safe it is required that security in this area be improved. In order to demonstrate a commitment in maintaining a safe, well maintained environment for service users it is required that the home comply with the requirements and recommendations of the Environmental Health Officer’s report, including that a window restrictor is fitted to a first floor bedroom window. It is also required that attention is given to improving the front garden area. Due to a build up of dust it is required that the ceiling fan in the kitchen is cleaned and consideration be given to replacing the mirror in the first floor bathroom. 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. Court View DS0000003382.V345140.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Court View DS0000003382.V345140.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective, and current service users have the information they need to make an informed choice about where to live, current service users have an individual contract in place. Individual’s aspirations and needs are assessed and monitored by the home EVIDENCE: The following requirements and recommendations were made at the last site to the home in December 2006 and therefore were reviewed as part of this site visit: The home’s Statement of Purpose needed to be updated and service users’ individual licence agreements were in need of review in order to ensure they fully reflected fees charged at the home. The home has in place a detailed statement of purpose. This was found to contain all of the required information in order that individuals’ can make an informed choice as to whether the services and facilities provided are suitable. The document is readily available to service users and their relatives. This document contains information about the management structure of the home, information about staff ratios and training, information about the home and how individuals are supported in aspects of their life, as outlined within their individual plan of care. The statement of purpose outlines the aims and objectives of the home, which promotes and supports individual’s rights. Furthermore there is information about the Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 10 admissions process and how individuals can make a complaint if they are not happy. Following a review at the last site visit to the home a requirement was made that all service users must be issued with a completed licence agreement outlining the fees charged by the home. The documents for three individuals were examined during this site visit and it was found that this requirement had been met. These agreements contained clear information about the fees individuals are expected to pay, information about safety within the home, visitors and notice periods. As there have been no new admissions to the home for a number of years and the current service user group is settled the admissions processes for the home this was not reviewed during this site visit. However, comprehensive care management and care plans have previously been seen on file. The home has developed comprehensive person centred care plans based on wishes and choices from the information provided by the service users as part of the ongoing placement within the home. The daily records maintained within the home provide clear evidence that individuals’ current and changing needs are identified and met. Clear information was in place to show the involvement of specialist services and professionals, ensuring a multi-disciplinary approach. Court View DS0000003382.V345140.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users care plans reflect their needs, how they wish to be supported and how they make decisions about their lives. Every effort is being made to ensure any risks associated with the care of service users are identified and action taken to reduce the risk. EVIDENCE: The following requirements and recommendations were made at the last site to the home and therefore were reviewed as part of this site visit: • • • • Service users care plans must be kept under review. Service users risk assessments must be kept under review Opportunity plans to be reviewed and completed fully. Consideration should be given to the terminology and language used in service users records. The care and associated documentation for three service users were fully examined during this site visit. All care plans reviewed showed a clear Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 12 understanding of the individual needs of service users, they contained clear guidelines for staff. In addition to the main care plans the home also had information about behavioural strategies to support individuals with complex needs and daily support information. Daily records and associated care documentation were well written with no concerns identified in respect of inappropriate terminology or language used. Opportunity plans for individuals in respect of services users wishes and choices for future planned activities had all been well written and are reviewed on an ongoing consistent basis. It was very evident from talking with staff and the individuals living in the home that people receiving a care service can choose when to get up and retire to bed and information seen evidenced other choices and opportunities that individuals are given. People had their own recorded daily routines and it was evident that they had been involved with the ongoing development of their care plan. Through observation of responses when dealing with individuals it was evident that staff have a good understanding of individual’s support needs, this was evident from the positive relationships, which have been formed between those living at the home and staff. Where any risk to a service user is identified risk assessments are completed to ensure their safety. Risk assessments had been reviewed in the past year. Staff have signed the assessments to demonstrate they have read and understood the risks associated with the care of service users. Records are stored safely and are able to be locked away. The home has a clear confidentiality policy that covers aspects of written and verbal information. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported to participate in activities of their choosing and to maintain relationships with their family. EVIDENCE: All of those in the home have learning disabilities, and some have limited communication skills. However, the information seen within care records demonstrated that individuals are encouraged to participate where appropriate in making choices and decisions upon day-to-day issues which affect their well being. Staff have become skilled at recognising how choices are made, for example, through observation of individuals’ language, expressions and individuals’ behaviour. Evidence in care records showed that staff support individuals to become part of and participate in, the local community in accordance with assessed needs and individuals’ wishes. Information seen in care records show that staff have helped individuals with their integration into community life through making Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 14 use of local facilities and activities such as shops, pubs, shopping centres and attending day services. Activities and outings are organised in accordance with individuals’ expressed wishes. During the inspection staff were observed asking Individuals for their views and opinions and were encouraged to make choices on aspects that affect their life. Staff on duty interacted well with the service users and used individuals’ preferred form of address. Since the last site visit to the home the staff have worked with service users to develop communication skills, this has included a staff photo board in order that service users can easier identify staff members. It was noted that there is not a picture of the manager and it is recommended that this is added in order that service users have full information of the staffing at Courtview. Information was recorded within care documentation of individuals’ likes and dislikes and special diets that are catered for at the home. The kitchen was found to be clean and tidy with good stocks of both fresh and frozen foods. Records seen demonstrated that individuals are offered alternatives and choices at mealtimes. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported in their preferred manner and individual’s physical, emotional and healthcare needs are well met. EVIDENCE: The following requirement was made during the last site visit to the home and therefore was reviewed during this site visit to the home. It was required that clear protocols should be in place in respect of medication that is given ‘as and when required’. Full systems of medication administration and recording and storage were reviewed at this visit all areas were found to be safe and in line with organisational policies and procedures in place. Records in respect of ‘as and when’ medication had been well written with clear individual protocols in place. Staff have all received training and have been deemed as competent. The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner. Evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody and that specialist advice is obtained when needed. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 16 Prior to the inspection a comment card was received from a general practitioner and one comment card was received from health/social care professionals who visit services users at the home. All the feedback received was consistent in that all agreed that the home communicates clearly and works in partnership in order to ensure the needs of individuals are met, that the staff demonstrate a clear understanding of the care needs of the service users and that management/staff ensure that any specialist advice is incorporated into the service users plan. All also said that they were satisfied with the overall care provided to service users at the home. An additional comment was ‘very good home, excellent staff and carers who look after patients very well’. There were good records of individuals’ healthcare needs and how they are monitored and how individuals’ assessed needs are met. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 22. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives can be confident that they are listened to and that any complaint would be responded to appropriately. Service users are suitably protected from abuse, however the home must ensure that security of service users money is improved. EVIDENCE: It was noted that care plans files contained a copy of the proceedure for making a complaint with evidence to show that this had been discussed with individuals. Comment cards received from service users recorded that individuals knew who to speak with if they had any concerns. Individuals have been given a copy of the complaints proceedure and this was seen in individuals’ files. No issues of concern were raised during the inspection visit. Staff knew and understood the organisation’s complaints policy and demonstrated that they would respond appropriately. The home has a book in place to record issues, concerns or complaints, there was nothing recorded at this current time. The policies and procedures relating to the Protection of Vulnerable Adults were in place. There was good evidence that the home systematically ensures that staff are trained to enable them to identify abuse and follow correct procedures for reporting suspected or alleged abuse. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 18 A review of a sample of service users money showed that money held corresponded with records held at the home, receipts are kept and money is checked regularly throughout the shift. However it was noted during the site visit that the safe was left with the keys in the door, this practice is unsafe and must stop. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Courtview is a homely, comfortable and safe environment however this would be improved if attention were given to the front garden area. EVIDENCE: Courtview is a detached, two stored property situated in a quiet lane in the rural location of Pucklechurch. There is a main bus route located nearby as well as local shops and amenities. All rooms are single occupancy and are well furnished to individual’s tastes. The lounge and dining areas are well decorated and comfortable, the rooms are enhanced through soft furnishings such as pictures, photographs and plants. The following recommendations were made during the last site visit to the home and therefore were reviewed as part of this site visit. It was recommended that the bath panel on the ground floor to be repainted and Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 20 also that consideration to be given to the redecoration of the bathroom on the ground floor. Both of these areas had been addressed. There is a spacious rear garden, which is well tended; however, this cannot be said for the front of the house. Due to rubbish and overgrown area to the front of the home a recommendation was made at the last site visit to the home that attention to be given to the front garden. Although it is acknowledged that staff have cleared some of the area further work is needed to make this a safe and accessible area for service users therefore it is required that attention be given to this area of the property and this will be reviewed by the inspector within the agreed timescales. There are bathroom facilities on both the ground and the first floor, it was noted that a ‘mirror’ in the first floor bathroom was distorted; this was as it was not made of glass. It is recommended that this be either replaced, or alternatively removed. The kitchen is domestic is size and fittings, this was found to be generally clean and tidy, however it was noted that a ceiling fan was in need of a clean. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained and have the right manner and approach to support individuals with complex and diverse needs. EVIDENCE: The staff members on duty were able to demonstrate that the manager and the staff team have developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations. These are well recorded in individual’s records. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. The recruitment and selection documents for the staff team were not available for inspection at this site visit, there have been no previous concerns in this area. There is an established staff team at Courtview who were able to confirm they had been recruited and selected in line with the Trusts policies and procedures. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 22 The Trust has a dedicated learning and Development Department to ensure staff members are appropriately skilled to meet the diverse needs of the people accommodated. Staff spoken with and certificates seen in individuals files provided confirmation that the training had been undertaken and staff were positive about how training, including protection of vulnerable adults, National Vocational Qualification and person centred approaches had, had a positive influence on their practice. It was noted during the last site visit to the home that there are occasions when staff are left alone working at the home, in order to ensure the safety of both service users and staff a requirement was made that a lone working policy to be developed by the Trust. The home has fully evaluated this area and has developed a document for the home in order to demonstrate that the safety of those both living at working at the home have been considered. All of the comment cards received from individuals who live at the home recorded that they are able to make decisions on how to spend their time, that the staff treat them well, that carers listen and act upon what the say. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and committed staff team. There are improvements required in order to fully ensure the health and safety of all. EVIDENCE: Ian Knowles is currently the temporary manager at the home; he works at the home part time and also at another home within the Trust. Staff have said that he is available and is supportive, however in order for continuity and further development of the service it is required that long term permanent arrangements are made for the management of the home. Staff spoken with said that morale at the home had much improved, that the manager was open and approachable and listened to new ideas. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 24 The following requirements and recommendations were made at the last site to the home and therefore were reviewed as part of this site visit: • • • The Commission must be notified of any incident that affects the well being of individuals who live at the home. Records of incidents, which are detrimental to the welfare of service users, must be maintained. Monitoring behaviour records should be better maintained. Following a review of documentation, discussion with the manager and staff it was found that the home have kept the Commission well informed of any incidents, which have affected the wellbeing of individuals at the home and have demonstrated that incidents have been dealt with effectively. Records of incidents and behaviour monitoring are better maintained with clear accountable recording in these areas. During this site visit the inspector was accompanied by a health and Safety Officer from South Gloucestershire Council; they did a tour of the premises and on the whole found the home to be safe and satisfactory, however it was noted that a first floor window was in need of a restrictor to stop service users potentially falling out and they also found some gas containers which required better storage it is required that the home comply with the requirements and recommendations made within the EH officers report, these will be reviewed during the next site visit to the home either by the inspector or the EH officer, whichever comes sooner. The inspector viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. The inspector saw the fire panel in working order. There are clear equal opportunities policies within the home and all staff are given copies of these. Staff meetings are held regularly and there are also other strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, service users review meetings, quality assurance, and an open and approachable management approach The Trust has well-established policies and procedures within the home and these are appropriate to the service provided and those who are being supported at the home and would provide information and clear guidance for those staff that work at the home. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 26 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard YA37 YA23 YA28 YA42 Regulation 8 16 16 13 Requirement Permanent arrangements must be made for the management of the home. Service users monies must be held securely. Make arrangements to clear the garden of rubbish and where it has overgrown. The home must comply with the report completed by the Environmental Health Officer Timescale for action 18/02/08 18/09/07 18/11/07 18/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard YA27 YA30 YA7 Good Practice Recommendations 1 2. 3. Mirror in the bathroom to be replaced. Ceiling fan in the kitchen to be cleaned Photograph of the manager to be added to the staff photo board. Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West RO 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Court View DS0000003382.V345140.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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