Inspection on 28/12/06 for Court View

This inspection was carried out on 28th December 2006.

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 7 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 18/09/07

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 28th December 2006 09:30 Court View DS0000003382.V315906.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.V315906.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.V315906.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) No registered manager in post. Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Court View DS0000003382.V315906.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 February 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.V315906.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 inspection that was conducted in order to look at the one recommendation made at the last announced inspection that took place on 28th February 2006 and also to monitor the care and services provided to those who live at the home. During this inspection time was spent examining care documentation, service users care plans, risk assessments and essential lifestyle documents, an examination of health and safety documentation, some areas of the home were viewed and also some discussion took place with service users and staff employed at the home. Further discussion took place with the staff on duty in respect of the Commission’s commitment to improving service’s through its ‘inspecting for better lives’ programme and how this would inform the inspection process and also the quality rating completed by the Commission about the service. Throughout the inspection process the staff members spoken with were informative and engaged fully with the inspection. Service users appeared relaxed and ‘at ease’ in their home. The inspector received three comment cards from those who live at the home, two from relatives and two from health professionals and the feedback given has been incorporated into the body of the report. What the service does well: What has improved since the last inspection? One recommendation was made at the last inspection; this was that a copy of the homes complaints procedure be put on public display in the homes entrance hall. This had not been displayed, however, it was found that staff had spent time with each service user in October 2006 and staff had explained and discussed the Trust’s complaints procedure with them. No complaints were raised in any of the comment cards received prior to the inspection from either service users or their relatives. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 6 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. Court View DS0000003382.V315906.R01.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 Court View DS0000003382.V315906.R01.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, 5. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is clear information for prospective service users to the home about the facilities and the services provided at the home, however the statement of purpose and individuals terms and conditions of their placement require some updating in order that the information contained within these documents are accurate. EVIDENCE: Courtview is managed by Aspects and Milestones Trust and is registered with the Commission for Social Care Inspection as a care home for 5 adults with a learning disability aged from 18 to 65, there are currently no vacancies at the home and have not been for some time. There is one individual living at the home is 66 and the home have been advised to apply for a minor variation in order to accommodate this person. The home’s admission processes were not reviewed at this inspection, it was not felt that this was appropriate as there have not been any new admissions to the home for a number of years. There is a stable group of people who live at the home and there are no vacancies at the home. Records in place showed that service users were originally admitted to the home following a full care management assessment these ensured that all Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 9 aspects of care provision were assessed with information in place to direct staff as to how these would be met. There is a Statement of Purpose in place at the home. This documents records who can be accommodated at the home; it provides information about the accommodation at the home, the process for admission into the home and how individuals are supported to make a complaint. The document gives information about the staffing arrangements and management of the home. It is required that this document is updated in order to provide accurate information about the management arrangements at the home as Mr P Chard is no longer the registered manager at the home. It was further noted that all service users had a copy of the statement of purpose and service users guide within their own individual file. Of the service users files viewed all had in place a copy of the ‘terms and conditions’ of their placement. These are entitled ‘License Agreements’. These outline the rights and responsibilities of both the service users and the registered provider. These documents record the ‘rules’ of tenancy and these were seen to be reasonable. It was noted that all of the documents had been signed by the service user and a representative of the home. Of the three agreements viewed only one had recorded the fees per week. It is required that these documents are reviewed and updated in order they reflect what the fees are and also what is not included within these fees, such as use of the homes vehicle and costs for holidays. There are individuals living at the home who do not use spoken language as their main method of communication. Information seen in individuals care records clearly showed that staff have established professional caring relationships with individuals and have recorded the complex indicators that clients use such as body language and behaviour, this demonstrates a commitment from the staff team to ensure that the needs of individuals are met. Information seen in care records showed that when specialist advice had been required in order to fully support individuals this had been sought; examples of external support included care mangers, consultant psychiatrist and the community learning disabilities team Court View DS0000003382.V315906.R01.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, 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care planning documentation at the home contains clear, detailed information to enable individuals personal, emotional needs to be well met, with individuals being supported and encouraged to make decisions that affect their life, However these documents must be kept under regular review and be updated where required. EVIDENCE: Information seen by the inspector, and confirmed by staff, and information seen recorded within individuals’ care records showed that those living at the home are offered a variety of social activities. Individuals are able to participate or not, this is dependent on the individual’s choice. The care plan documents for three service users were reviewed at this inspection; records reviewed included; opportunity plans, health action plans, essential lifestyle information including likes and dislikes and communication support needs. It was noted that one of the care plans had not been reviewed or updated since January 2006. It is required that care plans are reviewed a Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 11 minimum of every six months, or sooner should individuals needs change. Information seen had been well written and provided a ‘pen picture’, this included historical information about the individual as well as current information that was important to the service users. Information generally had been written in a positive way and were able to guide and direct staff in order to support and maintain individuals independence accordingly. Information had been written in a ‘person centre way’ and it was clear that the individual service users had contributed to the information held about them and their wishes had been incorporated within their plan of care. Each person has a daily dairy in the home in which staff record the routines, activities and behaviours, these are completed on a consistent basis with each entry being dated and signed by the staff member. It was noted that some entries were judgemental and not factual, it is recommended that consideration be given to the language and terminology within these reports. On the day of the inspection a number of individuals were out partaking in activities of their choosing, one of the service users went with a staff member to the bank, another went out for lunch and another went out with a day care support worker. Records in place show that staff enable service users to take responsible risks, ensuring that there is good information in place on which to base decisions, within the context of individuals care plan and the homes risk management policies and procedures. Records seen demonstrated that action is taken to minimise identified risks and hazards and service users are supported with their personal safety appropriately without limiting the individuals preferred activity or choice. Identified recorded risks seen included however it was noted that one service users risk assessment had not been reviewed since, these must be updated in order to ensure that individuals are partaking in activities without limitation an d within an identified risk management framework. Records are held securely in the home with confidentiality being respected. Court View DS0000003382.V315906.R01.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, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s lifestyles match their expectations and preferences and satisfy their social and recreational interests and needs. Service users are supported to exercise choice and control over their lives. EVIDENCE: The home have developed opportunity plans for each service user, these are linked into individuals goals that they wish to achieve and records the steps as to what action will be taken and who will support them. These opportunity plans also linked into individuals care plans and were reviewed at both key worker meetings and day care support reviews. It was evident that generally individuals had been well supported to achieve goals such as going away on holiday, visiting a chocolate factory and attending musical shows. It was noted that some of these plans had not been reviewed since February 2006 and it is recommended that thee are monitored and implemented to ensure that individuals are given choices and opportunities. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 13 Two comment cards were received from relatives of those who live at the home; both commented that they kept informed of important matters affecting their relative that as their relative is unable to make decisions that they are consulted about their care. Both also recorded that they were satisfied with the overall care provided. Three comment cards were received prior to the inspection from service users who live at the home all were supported, due to their communication needs, with the completion of this form by care staff who are employed at the home. All responded that they can do what they want during the day, evening and weekends. All knew who to speak with if they were unhappy. All responded that staff always treat them well and that carers listen and act upon what service users said. No concerns or issues were raised in any of these questionnaires or during the inspection. On the day of the inspection service users were offered a light lunch, one of the service users went out for lunch with a day care support worker. Records demonstrated that individuals likes and dislikes were recorded and staff confirmed that there are no special dietary requirements for individuals who live at the home and that individuals are supported to eat a healthy nutritious diet. The kitchen was found to be clean and tidy with items appropriately labelled in the fridge. Food stocks contained a variety of food choices with named brands purchased. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. Individuals are supported in their preferred manner and individual’s physical, emotional and healthcare needs are well met. Medication is managed in line with legal requirements. The aging, illness and wishes in the event of death are handled with respect. EVIDENCE: Staff described how they monitored an individual’s wellbeing and much was done via observations, as individuals did not always articulate their needs coherently and logically. This further evidenced that staff had a good awareness of the needs of those individuals with communication differences. Information seen recorded in care plans outlined the wishes and choices of individual’s in respect of the personal care support that is required by them and had recorded the ways in which they wished to be assisted. All rooms are single occupancy, bathrooms have locks ensuring privacy. The home operates a key worker system. This system ensures that each service user is allocated a named member of staff who supports them on a one to one basis and this staff member would participate in review meetings and is responsible for developing a relationship with the service user and for maintaining up to date records. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 15 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. All are supported by staff to attend healthcare appointments. Records seen evidenced that service users are offered annual health checks including optician and the dentist, and specialist services are also available to individuals such as occupational or physiotherapy and advice is sought if required from the community learning difficulties team. Prior to the inspection a comment card was received from a general practitioner who visits service users at the home. Their feedback was that the home communicates and works in partnership with them, that they are able to see individuals in private, and that staff demonstrate a clear understanding of the needs of service users. An additional comment made was that there is ‘very good care of patients’. Another comment card from a different health professional who visits the home commented that ‘as management has changed at the home there have been some difficulties that have affected their work’, an example being that they were asked to provide training for staff but there appeared to be some miss communication and the training didn’t take place all of whom it was intended for. Systems of medication administration, storage and recording were reviewed at this inspection. The inspector has seen at previous inspections that the home has clear policies and procedures in place to direct staff and provide instruction. Medication is stored in a locked cabinet with an additional facility for the storage of controlled medication. A monitored dosage system of medication administration is in place at the home and this appears to work well. There are some service users who are prescribed medication to be taken ‘as and when’ required. Staff were able to demonstrate in what circumstances` this medication would be given, however in order to fully ensure that medication is given appropriately it is recommended that clear protocols are developed for individuals as to what is deemed to be an appropriate time to administer medication and when it is not and what other methods may be used as an alternative method of support. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s can be confident that their complaints would be listened to and taken seriously and staff demonstrated a clear understanding in this area with clear policies and procedures in place. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals, this includes a protection of vulnerable adults policy and a protection of vulnerable adults policy that has been developed by South Gloucestershire’s Community Care department. A staff member was asked what their actions would be should they have any concerns over a vulnerable adult, they were very clear on their responsibility to ensure the protection of those within their care and would have no hesitation to report and concerns to their line manager. 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 and this was confirmed when talking to clients during the day. No issues of concern were raised during the inspection visit One recommendation was made at the last inspection; this was that a copy of the homes complaints procedure be put on public display in the homes entrance hall. This had not been displayed, however, it was found that staff had spent time with each service user in October and had explained and discussed the Trust’s complaints procedure with them. No complaints were Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 17 raised in any other the comment card received prior to the inspection from either service users or their relatives. Upon arrival at the home staff were undertaking an audit of service users monies in order to ensure it tallied with records held. All was correct and accounted for. Inventories are maintained of individuals belongings and it was seen that when new purchases are made these are added and an accurate records are maintained. From discussion with staff it was evident that staff were fully aware of their role and responsibilities in respect of protecting individuals living at the home and have acted appropriately when they have been concerned over the behaviours of individuals in order to ensure their rights and wishes are protected. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 18 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. The relationships between staff and those living at the home are good, and this creates a warm, supportive, safe environment, which promotes a good quality of life for the individuals living at Courtview. Furthermore individuals live in a homely, comfortable and safe, clean and, on the whole, a well-maintained environment. Attention should be given to the front garden and ground floor bathroom areas. EVIDENCE: Courtview is located in the rural village area of Pucklechurch. The house is a detached two-story house with five single rooms for service users use. The house is within walking distance to local shops, a coffee shop, public house a church and local shops. The home has a spacious lounge and dining area, both of which are well furnished. All areas of the house were found to be clean and tidy. Records showed that service users, where they are able , are supported with areas of daily living within the home with service users participating in tasks such as keeping their Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 19 own rooms tidy, preparing drinks and snacks and putting their own laundry away. Service users have a large well maintained garden to the rear of the house. It was noted that the front garden area of the house is in need of attention. There are overgrown areas and garden rubbish The inspector viewed two residents private rooms this included the room for a service user that had formally been an office and had been reverted back to a bedroom. Thus providing a much improved, larger area for the service users private use. The service user told the inspector they were happy with the move and liked their room. Both rooms viewed were found to be well decorated and furnished appropriately. It was clear that service users had been supported to personalised their rooms in order to reflect their own taste and choices, rooms were homely. Lighting within the home is domestic in style and of a good standard, emergency lighting is provided throughout the home, this is checked on a monthly basis. The home has sufficient toileting and bathing/showering areas for individuals use. These areas are close to people’s rooms. It was noted that the bathroom walls on the ground floor had peeling paint and the wooden bath panel was chipped. It is recommended that consideration is given to the redecoration of this room and that the panel is repainted. A hand test of the water temperature found the temperature was not excessive and was at a safe level, the temperature in the home was warm and comfortable. At the time of the inspection all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal and communal space. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 20 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, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are staff employed at the home and there is a full staff team, in order to ensure the safety of both service users and staff it is required that a ‘lone working’ policy is developed by the organisation. EVIDENCE: This was an unannounced inspection and there was no manager present at this inspection and therefore the recruitment and selection documents as well as training and supervision records were unavailable for inspection. There have been no historical issues or concerns over staffing at this home. Staff rotas were viewed and the current 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. There are no volunteers working at the home. On the day of the inspection two staff members were on duty, both were fully conversant with the care plan support needs of individuals living at the home including their communication, physical, health and emotional support needs. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 21 Staff were aware of the aims and objectives of the organisation. Staff were aware of their own knowledge and skill limitations and knew when it was appropriate to involve someone else with more specific expertise. Information such as correspondence and assessments seen on care records confirmed that specialist services were accessed when a need had been identified and had been responded to promptly. Staff spoken with said that ‘moral is good at the home’. There are occasions when services users are left in the house with only one staff member. This happened on the day of the inspection when a staff member took a service user to the bank. In order to ensure the safety of all it is required that the trust develop a lone working policy in order to fully evaluate the situation. Although supervision records could not be viewed at this inspection; staff on duty said that they received one to one supervision at least once a month with their manager. Meetings were recorded and provided an opportunity to discuss work performance and continuity of care for service users. The inspector saw a timetable of forthcoming supervisions that had been arranged with staff. Staff can have access to the homes written grievance and disciplinary procedures. There are also procedures in place for dealing with physical aggression towards staff. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 22 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. There is not a permanent manager in post at the home. The home has good quality assurance processes in place however service users interests would be better safe guarded if record keeping were improved at the home. There are safe working practices at the home, which are underpinned by the organisations policies and procedures. EVIDENCE: The registered manager of the home is Mr Philip Chard. Mr Chard is not currently working at the home and has been transferred to work in another Aspects and Milestones residential care home. The Trust notified the Commission of the temporary arrangements of the management of the home, which is currently that there are two part time managers, one is a support worker who has been promoted, and the other manager is based at another home. Staff confirmed that this manager visits the home regularly and Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 23 provides advice and guidance when needed. Once the permanent arrangements have been made in respect of Mr Chards position the Trust must decide the long term management post at the home in order that both service users and staff are supported and directed in order to meet the stated aims and objectives of the organisation. The organisation have ensured that so far as is reasonably practicable the health and safety of service users and staff. 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. During discussion with staff to verify information seen in care records and incident reports it was clear that since the last inspection there had been a number of incidents which should have been reported to the Commission, which had not. It was further found that incidents that had occurred at the home and had not been recorded in line with the organisations incident procedure. The Trust has developed good quality assurance initiatives within the organisation. Staff have developed a system based on seeking the views of service users. The inspector saw that each service user had been supported to complete an in depth questionnaire in order to seek their views in a number of areas such as; in house relationships, house hold involvement, healthcare, shared facilities. Staff had also specifically asked ‘we want to know how we can make life good for you’. Answers received had been incorporated into individual’s action and opportunity plans with information as to how identified areas would be addressed ensuring a positive outcome for the individual. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 2 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 3 12 X 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 X 3 3 2 2 X Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 25 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. 5. Standard YA1 YA5 YA7 YA9 YA42 Regulation 4(1)(c) 5(1)(b) 15(2) b 13(4) b 37 Timescale for action The homes Statement of Purpose 28/02/07 to be updated. Licence Agreements to fully 28/02/07 reflect fees charged at the home. Service users care plans must be 28/01/07 kept under review. Service users risk assessments 28/02/07 must be kept under review. The Commission must be notified 28/12/06 of any incident that affects the well being of individuals who live at the home. Records of incidents, which are 28/12/06 detrimental to the welfare of service users, must be maintained. A lone working policy to be 28/02/07 developed. Requirement 6. YA41 17(1) a 7. YA33 12(1) a 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 YA7 Good Practice Recommendations Consideration should be given to the terminology and DS0000003382.V315906.R01.S.doc Version 5.2 Page 26 Court View 2. 3. 4. 5. 6. 7. YA24 YA24 YA28 YA41 YA6 YA20 language used in service users records. The bath panel on the ground floor to be repainted. Consideration to be given to the redecoration of the bathroom on the ground floor. Attention to be given to the front garden. Monitoring behaviour records should be better maintained. Opportunity plans to be reviewed and completed fully. Clear protocols should be in place in respect of medication that is given ‘as and when required’. Court View DS0000003382.V315906.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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.V315906.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. 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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