Inspection on 19/09/07 for Nelson House

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nelson House 05/12/06

Nelson House 23/11/05

Nelson House 12/07/05

Nelson House 24/02/05

Nelson House 04/11/04

Nelson House 08/03/04

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Nelson House Brimscombe Hill Stroud Glos GL5 2QP Lead Inspector Mr Paul Chapman Unannounced Inspection 19th September 2007 09:00 Nelson House DS0000016507.V336431.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 Nelson House DS0000016507.V336431.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. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nelson House Address Brimscombe Hill Stroud Glos GL5 2QP 01453 887721 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) www.nelsontrust.com Nelson House Recovery Trust Josephine Hazel Wickes Care Home 16 Category(ies) of Past or present alcohol dependence (16), Past or registration, with number present drug dependence (16) of places Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2006 Brief Description of the Service: Nelson House is an adapted Grade II listed building and is registered to accommodate up to 16 adults who are recovering from drug and/or alcohol addiction. Accommodation is provided over three floors with a range of communal rooms. All bedrooms are doubles as it is considered part of the rehabilitative process that residents must share to avoid isolation. The counselling programme is delivered at a nearby adapted old school building and the Trust also runs a training and education centre close by. Nelson House is part of the Nelson House Recovery Trust which comprises the residential care home and also a number of supported housing projects in Stroud and Gloucester. Residents from these houses may also attend the counselling facilities and the training and education centre. Fees range from £602.00 to £702.00 per week. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. On arrival we went to the main office of the Nelson Trust and met the registered manager before going up to the home. At the home we were met by two staff who supported us throughout the inspection. A tour of the premises was completed and records for health and safety were examined, in addition to this policies, procedures and medication administration were examined. Whilst in the home all of the people currently there were asked whether they would like to speak with us. Four people met with us and spoke at length about their admissions to the home and what it was like to live there. Peoples care records were examined in detail and showed that needs were assessed and care plans developed to meet those needs. People spoken with confirmed that their needs were being met. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing considerable information about the service and plans for further improvement. In addition to the CSCI receiving the AQAA a number of completed surveys were also received. What the service does well: There is an excellent assessment process that means people are thoroughly assessed before they are admitted to the home. Each person spoken with confirmed that they were involved in this assessment process. People stated that the staff are “open, friendly and supportive”. Observations during the day of the inspection confirmed this. Each of the people spoken with stated that they were involved in developing their care plans and that their goals were met. Comprehensive evidence was available of people’s goals being met. People commented that they thought the role of house leader was good as it gave back responsibility. Good activities are provided in the home with the use of the day service and an outward-bound course. People commented really positively about the outwardbound course. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 6 People are supported to attend groups including narcotics and alcoholics anonymous in the surrounding areas. People commented that they thought the food was nice. The home make good use of other professionals to meet peoples needs. A thorough recruitment process protects people living in the home. Health and safety around the home is monitored regularly and this helps to minimise potential risks to people living in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Nelson House DS0000016507.V336431.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 Nelson House DS0000016507.V336431.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): 2, 4, 5 People who use the service experience Excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are thoroughly assessed by appropriately qualified staff which minimises the potential risk of people who’s needs can not be met being admitted to the centre. People who may be potentially admitted to the home are able to visit before they make a decision. EVIDENCE: Four people currently living in the centre agreed to speak with us. All people agreed that before they were admitted to the centre they were asked to complete an assessment with staff from the centre. We examined the files for these 4 people in detail; each contained the assessment they spoke about. Each of the assessments was detailed providing staff with the information about peoples needs and their goals/aims. These assessments form the basis of the care plans developed between the people living in the treatment centre and the staff. Where people are funded by a local authorities community care assessments were available. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 9 All of the people spoken with visited the centre before they moved in. They all agreed that the other centres they had seen were more “clinical”, and that the atmosphere at Nelson House was nicer. Each person received written conformation that they were to be offered a place in the centre. One person made a comment about the “buddy system”. This is a system that when a person is admitted another person already living in the home is “buddy’d up” with them to show them different things around the home (meal times, group sessions, etc). They stated that there seems to be a great variation in the standard of this, with some people feeling really supported by their buddy, whilst others feeling a little isolated. This was brought to the attention of the registered manager. They showed the inspector the procedure for the buddy system which clearly states the expectation of what it means to be a buddy. The inspector and manager discussed this and it was agreed that maybe this should be reviewed with people before they become a buddy. A requirement of the previous inspection report was that a policy must be developed to address the temporary discharge of people from the home. This has now been completed and meets these standards. Nelson House DS0000016507.V336431.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed and care plans are developed to meet them. Care plans are followed by staff and this results in people’s needs being meet appropriately. Completed risk assessments minimise the potential risks to people while they are living in the home. EVIDENCE: The personal files examined provided staff with detailed information about each person. Each file was seen to contain a client passport identifying personal details, current medication, care manager details and identified addiction. Other information made available included a copy of the letter confirming a person’s placement, completed needs assessment, clinical assessment, therapeutic contracts, risk assessments and notes from sessions with counselling staff. Each person stated that they have a named counsellor. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 11 Each of the people that spoke to us was positive about the counsellors and comments included “they are open”, “friendly”, “and supportive”. Assessments form the basis of people’s care plans. Each person who spoke to us stated that they had been involved in developing their care plans, and that their goals were achieved with the support of staff. Examination of the four peoples files showed that all but one person had detailed care plans present which had been reviewed regularly. There was a clear audit trail through care plans showing an initial goal being identified, that being achieved and a new goal being chosen and worked towards. Where it was identified that one person was missing a care plan this was brought to the attention of the manager. There was some evidence that a care plan was in place but could have been filed incorrectly. The manager stated that this would be addressed. Personal files contain guidelines for counsellors to follow. Guidelines seen included the centre’s policies/procedures on care planning, risk assessment and guidelines about the format for writing reports. Senior staff check reports written by the counsellors. The inclusion of these policies, etc is good practice as it promotes a consistent approach to these areas. Speaking with people they explained that as a group they agree the menu every week. The senior peer (house leader) and two others are then responsible for going to buy the ingredients. People agreed that they thought this was really good as it starts to “give back” responsibility. Every one takes it in turn cooking, one person said, “Some people cook more often than others because they are better at it”. People spoke about budgeting and that this was strict with the group not being allowed to spend more than the amount allowed. As identified earlier there is a house leader every week and also a deputy. Each Sunday people living in the home meet as a group to discuss any issues, the chores and the menu. The house leader takes the lead in this. All of the personal files examined contained risk assessments. The assessments seen covered areas including physical treatment of others, prescribed medication, self-harm, suicidal thoughts and sexual offences. In all but one case these assessments had been completed thoroughly, unfortunately the risk assessments in one person’s file were incomplete. This was brought to the attention of the manager. Nelson House DS0000016507.V336431.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): 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. The centre provides people with activities that meet their current needs. The food provided at the centre is chosen by the people living there who are responsible for preparing it. EVIDENCE: Standards 12, 13, and 15 are not specifically relevant to this client group. The centre provides people with a structured timetable of activities that are mainly based within the centre’s properties. As part of the centre there is a day centre, called the Star centre. The centre provides people with the opportunity to take part in activities such as bicycle maintenance, football, IT (information technology), woodwork, music, art, aromatherapy and pottery. People spoken with were really positive about these activities. People were enthusiastic about Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 13 the Friday afternoon sports sessions organised at a local sports centre. The sessions provide people with the opportunity to take part in games of football, squash and badminton. During the summer months staff organise “outward bound” days when groups going walking, caving, canoeing and complete other activities. People spoke to the inspector about completing these activities and some of the challenges they present. One person explained that they had been abseiling, climbing and canoeing whilst being at the centre and that “I would never have done this normally and was really chuffed to have been able to”. The centre uses Narcotics and Alcoholics Anonymous fellowships in the surrounding areas. Staff support people to attend by providing transport. There is an expectation that people will attend twice a week. Speaking with people they stated that transport and staff were always available to support them to attend these meetings. One person stated that they attend meetings 5 nights a week. Speaking with people they stated that they are enabled to see family and stay in contact with them whilst they are at the home. Some people said this could be limited as they need to focus on their treatment but they were happy with the arrangement. Weekly and monthly meetings are held with people where they are given an opportunity to discuss issues about the home. In addition to this they are able to speak individually to their named counsellor. People were in agreement that issues brought to the attention of their counsellors were addressed. Sometimes issues discussed as a group take longer to resolve. An issue discussed with us was the “lack of available activities on a Sunday”. People felt that there was nothing to do on a Sunday. This was discussed with the registered manager who stated this had been brought to their attention and changes were currently being discussed. Feedback from all of the people spoken with was positive about the food at the home. As highlighted earlier in this report people choose the menus and they are also responsible for preparing them. The menus seen during the site visit showed a good variation in the meals prepared. Speaking with two of the staff they explained that they are going to complete a course that will enable them to advise people on their diet and nutrition. This is good practice as there is huge importance in supporting people to regain/maintain a healthy diet. Nelson House DS0000016507.V336431.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home have access to the appropriate physical and emotional support as required and this ensures that these areas of their health are maintained. The service is taking steps to reduce the potential risks to people presented in the medication administration system. EVIDENCE: None of the people living in the house receive any personal care from staff. Records in the peoples’ files show that the appropriate professionals meet physical needs whilst the counselling team addresses emotional needs. When speaking to one person about their medical needs they stated that their medical needs had always been met throughout their 4 months in the home. At the previous inspection a specialist CSCI pharmacist inspector attended. A number of issues were highlighted with the home’s medication administration. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 15 As a result four requirements were made. To address these requirements the following steps have been taken: • In the week following this inspection the home were implementing the Monitored Dosage System (MDS) • New medication sheets have been implemented that allow staff to record the quantity received, and disposed of. • The appropriate staff have received medication training. The previous inspection report also highlighted the need for a written protocol about the use of homely remedies. Staff on duty were unable to find this protocol and the manager must ensure that it is developed and implemented. In addition to the requirements of the previous inspection report a number of recommendations were made, and the following steps have been taken to address these: • Each person requiring medication has an individual medication sheet. • Proper medication cabinets are being supplied with the MDS system being adopted by the home. • All people admitted to the home are asked to give their consent to staff administering their medication. The CSCI has met with the provider since the previous inspection to discuss the administration of medication to other areas of this service that are not registered with the CSCI. The discussion focused around the potential need to register other parts of the organisation due to the level of care provided when administering medication. At present the CSCI are waiting for the Department of Health to release the revised definition of personal care. Once this has been published another meeting will be held to discuss future actions. Nelson House DS0000016507.V336431.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. People are able to make a complaint if they are unhappy with the service they are receiving and the complaints procedure ensures that peoples’ concerns are responded to appropriately. Training in safeguarding adults minimises potential risks to people living in the home. Whilst people are staying at the centre there are supported by staff to manage their monies. EVIDENCE: Speaking with people they confirmed that they were able to make a complaint if they were unhappy about something. All of the people spoken with said that they felt they would be listened to if they did make a complaint. All of the people spoken with said they were happy with the service they were receiving at present. The CSCI has not received any complaints about the service since the previous inspection was completed. The home has a whistle-blowing policy for its staff. The training records supplied to the CSCI showed that 29 of the 60 staff have received training in safeguarding adults since the previous inspection was Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 17 completed. It becomes a requirement of this inspection report that the manager ensures all staff working directly with people have completed this training. People spoken with during the day were asked about their personal finances and how they were managed whilst they were at the centre. People explained the process and confirmed they were satisfied with it. Nelson House DS0000016507.V336431.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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service provides people with a homely, comfortable environment that helps to maintain their safety. EVIDENCE: A tour of the premises was completed with the registered manager and another staff member. All of the communal areas and the majority of the bedrooms were seen. The premises provide people with sufficient communal areas that include a lounge, dining room and kitchen. Since the previous inspection people living in the home are no longer allowed to smoke in the lounge and an undercover area has been provided in the garden. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 19 Generally the property is in a good state of repair: • • • • All of the halls and landings have been painted and some new carets have been fitted. The night support worker room has been damp proofed and redecorated. The TV room is to be redecorated to repair the water damage when the shower room upstairs has been replaced. This is an outstanding requirement from the previous inspection report. The main toilet, bathroom and secondary shower room are to be renovated/re-decorated. This is an outstanding requirement from the previous inspection report. The registered manager stated that work is due to start on these facilities on October 29th 2007. The carpet in the main lounge is stained and staff stated that they had recently cleaned it. It becomes a requirement of this inspection report that the carpet is replaced. • All of the bedrooms seen were tidy and reflected some of the interests of the people living in them at the time. Bedrooms are not individual and clients share their bedrooms with others. At the time of this inspection the home was generally tidy and there were no offensive smells. Nelson House DS0000016507.V336431.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): 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 training covers mandatory subjects as well as specialist topics to meet the specific needs of people living in the home. The home’s recruitment procedures are thorough which minimises the potential risks to people living in the home. EVIDENCE: Since the previous inspection the registered manager has complied a comprehensive list of the training completed by staff. A significant number of staff had completed in courses in the following subjects in the previous 12 months: - Safeguarding Adults, diversity, specialist counselling and other related courses, complaints management, first aid at work, medication administration. The home has a thorough recruitment policy and procedure and the files for people recruited since the previous inspection were examined. No shortfalls were identified. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 21 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a well organised service with good leadership that enables people to focus on their recovery. Policies have been reviewed and updated where required which enables staff to provide a consistent service. Potential risks to people are minimised through the staff’s auditing and other regular checks taking place. EVIDENCE: The registered manager has been in post for a considerable length of time and oversees the day-to-day running of the home and its compliance with the standards and regulations. In addition to the registered manager there are also therapeutic and clinical managers. A copy of the home’s employment liability insurance certificate was displayed. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 22 Regulation 26 visits are completed monthly by one of the Trustees. When completing them they will speak with people living in the home or their representatives, speak with staff, inspect the premises inside and out, examine records for medication, fire equipment tests and medication administration. A copy of these documents is then sent to the CSCI. We spoke to the registered manager about quality assurance. Some steps are taken to involve the people living in home, these include: • The weekly resident meetings where people have the opportunity to comment on the service they receive. • People are asked to complete a “tell us about it” form that asks for their opinions. • Recently the home held an open evening for local residents. Speaking to the manager we discussed how a quality assurance system could be developed. It was suggested that this could be based around the National Minimum Standards for Younger Adults. And, as well as people living in the home taking part in the process they could also ask funding authorities/care managers for their opinions. A format for this could be a tick sheet, or yes/no answer sheet that also gives people the option to write comments if they wish. It becomes a requirement of this inspection report that an effective quality assurance system is developed. Speaking with people throughout the day there was agreement that the service provided is excellent and is enabling people to recover from their addictions. Since the previous inspection the majority of the home’s policies have been reviewed and updated as required. Health and safety was examined. Staff complete monthly health and safety audits around the home and completed audits for previous months were examined. These showed that issues such as slips, trips and falls, cleanliness, electrical and fire safety, and first aid were all checked monthly and evidence was available to show that were required corrective actions were taken. In addition to these audits other steps are taken to minimise potential risks: • Hot water outlet temperatures are monitored monthly. Staff stated that they are currently arranging for a legionnaires test to be completed. • Fridge and freezer temperatures are recorded daily. • A food probe is used regularly to record the temperature of food produced. • Accident recording is thorough. • A fire risk assessment has been completed and reviewed. • Fire safety equipment is checked regularly, but the manager must ensure that alarms are tested weekly. This becomes a requirement of this inspection report. Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 23 • • A qualified engineer has completed a maintenance check of the alarm system. 2 fire drills have been completed since August. Nelson House DS0000016507.V336431.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 X 2 4 3 X 4 3 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 2 25 3 26 3 27 1 28 3 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 3 X 2 X Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA9 Regulation 13(4) Requirement Risk assessments must be completed for each of the people living in the home that identify and minimise potential risks. Introduce a written protocol for all non-prescription ‘homely remedies’ medicines used and make effective arrangements for secure storage. Outstanding requirement 01/03/07 All of the staff that work with people living in the home should complete safeguarding adults training. The registered manager must ensure that the carpet in the television lounge is replaced. Outstanding requirement 04/05/07 An effective quality assurance system must be developed that enables people living in the home to give their opinions. Fire alarms must be tested weekly from different call points. Timescale for action 30/11/07 2. YA20 13(2) 01/12/07 3. YA23 13(6) 01/02/08 4. YA24 23(2) d 01/02/08 5. YA39 24 29/02/08 6. YA42 23(4) c 09/11/07 Nelson House DS0000016507.V336431.R01.S.doc Version 5.2 Page 26 7. YA42 13(3) A legionnaire’s water test must be completed. 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The filing in people’s personal care files should be monitored to ensure that all of the necessary documents are present. Nelson House DS0000016507.V336431.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 Nelson House DS0000016507.V336431.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!