Inspection on 10/10/06 for Robleaze

This inspection was carried out on 10th October 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Robleaze 25/09/07

Robleaze 24/02/06

Robleaze 12/10/05

Robleaze 02/03/05

Robleaze 03/08/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Robleaze 537-539 Bath Road Brislington Bristol BS4 3LB Lead Inspector Sandra Jones Unannounced Inspection 10 & 13 th October 2006 09:30 th Robleaze DS0000026552.V315189.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 Robleaze DS0000026552.V315189.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. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Robleaze Address 537-539 Bath Road Brislington Bristol BS4 3LB 0117 9720813 NONE 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) Mrs Susan Mary Robinson Mrs Claire Louise Luton Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 10 persons aged 18 - 64 years Date of last inspection 24th February 2006 Brief Description of the Service: Robleaze is a care home operated by Sue Robinson and managed by Claire Luton. It is registered to accommodate up to ten adults of both sexes with learning disabilities. The property is situated on a busy main road close to shops, parks, amenities and bus routes. Two houses were converted to accommodate the registered numbers and maintain its appearance of a domestic dwelling, which blends with its local environment. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key visit was conducted unannounced over two days in October 2006 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the residents, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from residents and staff. Prior to the visit the inspector spent some time examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home, (Regulation 37’s). Ten questionnaires “Have your say” were sent to residents in the home prior to the inspection and ten were completed and returned. Information from these has been collated and is detailed throughout the report. What the service does well: Completed questionnaires were received from residents and relatives giving feedback about the standards of care at the home. Residents indicated that they can do what they want throughout the day, they know who to speak to if they are unhappy and the home is fresh and clean. Feedback from the residents during the inspection confirmed that the food served is good and keyworkers support residents with their independence living skills. It is clear that opportunities exist for residents to participate in activities. It is evident from the comment of a staff member that their role was about realizing that residents at the home are individuals and there is an expectation that staff support residents to be more independent. Staff recognise that residents have the potential to increase their level of skill and emphasis is placed on reviewing residents changing needs. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 6 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. Robleaze DS0000026552.V315189.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 Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The admission procedure must be further developed to include the assessments that will be undertaken to ensure that the needs of the potential resident can be met at the home. EVIDENCE: There is a clear admission procedure in place that describes the criteria for admission including introductory visits and trial periods. The procedure requires further development in respect of the assessments to be conduced for people that self fund their placements. The service provider explained that the resident group at the home is stable and there are no expected admission or discharges in the near future. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans reflect residents individual needs and action plans guide the staff to meet the need consistently. The service provider should continue to convene review meetings annually. Residents report that they are able to make decisions about their daily lives. Risk assessments are based on activities that may involve an element of risk. EVIDENCE: Residents files contain the individuals past history and personality profile. Brief background histories with the likes, dislikes and preferred routines are described and include activity timetables. Care assessments are based on personal hygiene, self-help and social skills. Action plans are then developed from the care assessment on each need identified. The person’s ability to meet the needs with the assistance needed is detailed in the action plans. A description of the actions to be taken to meet the need with the progress is also included. Residents giving feedback were aware of their care plans, knew the name of their keyworker and could describe the role they perform. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 10 It was understood from the service provider that previously care plan were amended following review meetings. The staff completed care assessments with residents in preparation for the review meetings. A Local Authority care manager has been appointed to convene review meetings. The meetings are now convened at short notice and relatives are not always able to attend the review meetings and care assessments are not completed in time for the meetings. The service manager should continue to convene the review meetings following care assessments which family can attend. One person has restrictions imposed because to the risk to the person and other people at the home. Electrical equipment cannot be left in their bedroom, wardrobe doors are removed and toolboxes are kept locked. Six residents at times may exhibit aggression and violent behaviour. Care plans detail the triggers and approach to be taken to divert and diffuse violent and aggressive incidents. It is the practice of the home to send residents to their rooms until they are calm. The action plans ensure that residents dignity is maintained during potentially aggressive and violent incidents. There are care plans based on positive behaviour are in place for three residents. Guidelines are in place to reduce repetitive behaviours and ensure that members of staff handle situations consistently. The manager reported that one resident has communication needs and two must be given time to respond. Two residents are assisted to make decisions by limiting the number of choices and fully discussing the implications of the choices. Care plans describe the method used by residents with communication needs. One person uses pictures, symbols and keywords to communicate, another resident is given additional time to respond and for another, staff prompt to slow down and not to cover their mouth whenever they are speaking. Care plans are clear about the assistance needed by the residents with finances. Money skills are included in care plans with the persons abilities described and the staff’s action to meet the need identified. Staff compile daily reports when shift changes occur and describe the routine undertaken, the support provided along with decisions made by he resident. Decisions made by residents are based on times to rise, retire and activities undertaken. Nine of the ten residents that responded through surveys indicated that they can usually make decisions about what to do each day. One person felt that they can always make decisions about their day. Risk assessments are in place for all activities that may involve an element of risk. During the care assessment, risk involved in the task are identified and Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 11 risk assessments are completed to supplement the assessed need. Risk assessments are in place for road safety, water temperature, meal preparation and using electrical equipment. The home maintains an accident book and since the last inspection, three accidents were recorded. Two accidents occurred as a result of aggressive incidents and the other was a fall. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. 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 the service. Opportunities exist for residents to experience meaningful activities within the community and with staff at the home. The staff support residents to use the local community facilities and integrate into community life. Relatives and friends confirmed through questionnaires that they are made welcome at the home whenever they visit. Residents are respected as individuals and supported to become independent. The format used to inform residents about the rules of the home must be reviewed to establish that residents can understand format used. The residents say that the meals served at the home are good. EVIDENCE: The service provider explained that members of staff arrange communitybased activities for residents at home during the day. There is a timetable of daily activities, members of staff at the home escort one resident to the shops to purchase the daily paper each morning. The group of residents at home on that day will then sit together and plan the day’s activity. The activity plan is prepared using words, pictures and symbols that list the people at the home and staff on duty. The weather and clothes that should be worn, the plan for the day, with the lunch to be served is included in the activity plan. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 13 Scrapbooks are then used to record the activity undertaken, for bowling scorecards are used and postcards for places of interest. The residents accommodated attend day care centres and four residents attend college courses. The residents consulted during the inspection described the activities that they undertake which entail community-based activities with day care centres and staff at the home. It was understood from the service provider that the staff accompany residents outside the home. The staff arrange group outings to the library, restaurants and bowling, at weekends 1:1’s are arranged with keyworkers. Residents use public transport to attend hospital appointments and shopping trips, for other journeys the home’s vehicle is used. All residents are registered onto the electoral roll. The home policy on visitors is based on maintaining friendships, and sets the steps that will be followed to strengthen links with family and friends. Professional visitors mainly sign the visitor’s book; the purpose and date of the visit are recorded. Two relatives returned questionnaires about the home and confirmed that visitors to the home are welcome and are kept informed about matters. Seven residents have visitors and the staff take one person to visit relatives fortnightly. During the inspection, one resident confirmed that the staff take him to visit relatives. Residents are provided with guidelines about how the home is run, the complaints procedure and confidentiality policy are included. Guidelines are based on respecting the individual, knocking on doors and waiting for an invitation to enter, meal times and routines. The rules about smoking and pets are also included, with the visiting arrangements and extra charges not included in the fees. The format must be considered to ensure that the residents can understand the guide. The service provider explained that there is a washing-up and drying-up rota. It is the practice that residents that lay the table must also wash-up. Residents are expected to do their laundry, ironing, assist with meal preparation and keep their rooms tidy. Residents consulted confirmed that they were expected to undertake household chores. Their comments indicated that the staff will support residents depending on their level of skill to complete the task. The kitchen was fully refurbished since the last inspection. The vinyl flooring was replaced with tiled floor, kitchen units were replaced and new appliances purchased. Menus in place are on a four-week rolling rota and the record of food provided evidences that residents have alternatives and a varied diet. There is a wide range of frozen, fresh and tinned foods at the home, which Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 14 reflects the menus in place. Residents giving feedback stated that they liked the food served at the home and the diet was varied. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Members of staff provide personal care that meets residents preferred routines. Residents health care needs is monitored at the home and where appropriate, specialist advice is sought. For residents to benefit from safehandling of medicines, medications administered for one person must not be used for another resident. EVIDENCE: Care plans describe residents abilities to manage their personal care. The staff assess residents abilities with bathing, hair, nail and dental care. From the assessments, action plans are developed incorporating residents preferred routines. Daily routines for rising, retiring and weekends is detailed in the personal profiles. Grab rails were installed in the downstairs bathroom for two residents that need additional support to maintain their independence with personal care. There is a keyworker system in operation. Residents are given the opportunity to select their keyworker and generally they coordinate residents care. Residents consulted knew the name of their keyworker and the roles they Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 16 performed. A keyworker policy is in place and staff must read and sign the policy to confirm their understanding of the role. The service provider stated that female residents are invited for routine screening and both residents are exempt from the checks. Two residents have continence difficulties and medical reviews have taken place and the diagnosis is behavioural not medical. Residents that have not seen their GP in 12 months, the staff arrange for residents to have annual health checks. Members of staff are expected to accompany residents on visits to the GP and hospital appointments. It is evident from the case records that staff monitor residents health and where appropriate seek referrals through the GP’s for specialist input. Residents access local NHS facilities, regular visits are arranged to the optician and dentist. A record of health care visits are maintained which describe the nature and outcome of health care visits. Residents confirm that staff accompany them on visits to the GP and on hospital appointments. Individual medication profiles describe the regime for administration, with the purpose and possible side effects. Appended onto the medication profiles are the information leaflets. Guidelines for when required medication are in place. While the guidelines state that permission from senior staff must be sought before administering the medication, the information must be made more explicit about the behaviours that must be exhibited before medication can be administered. Homely remedies administered from a stock supply when required are kept at the home. The records of administration were checked against the medications held and indicate that records are accurately maintained. Regular prescribed medications are administered from a monitored dosage system and indicate that staff sign the records immediately after administration. However, it was noted that one person’s medication was being used for another. “The Administration and Control of Medicines in Care Home and Children Services” states that medicines prescribed and dispensed for one person should not, under any circumstances, be given to another or used for a purpose that is different from which they were prescribed. It is acknowledged that members of staff took appropriate action to have residents medications delivered to the home in time. Medications for one person must not be used for another. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents were placed at risk from one member of staff and systems that lead from supervision through performance monitoring into dismissal and POVA referrals must be developed for future use. Policies and procedures in place assist staff working directly with residents to recognise forms of abuse and take appropriate action. EVIDENCE: The home has a detailed Complaints procedure, which describes the steps to be taken by the residents to make complaints. However, the format used must be considered particularly as there are a number of residents that are unable to read. The format of the procedure must be in a language that can be understood by the people its intended. To promote feedback from residents, copies of the procedure are handed to the person and there are opportunities for residents to raise concerns during residents meetings. Issues of concerns raised during residents meetings are based on group living, keyworkers and community activities. The residents indicated through surveys that they know who to speak to if they are unhappy and how to make complaints. Four complaints were received at the home about a member of staff. While the actions taken to address the issues raised were appropriated. The service provider should have taken further action about the performance of the staff involved. The service provider should have considered disciplinary and performance monitoring for this individual. It is acknowledged that this individual is no longer employed at the homes. Nevertheless, the residents were placed at risk from this member of staff and systems that lead from Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 18 supervision through performance monitoring into dismissal and POVA referral must be developed. The Abuse, Anti- Bullying, Whistleblowing and Finance policy demonstrates a commitment towards safeguarding residents from abuse. Staff working directly with residents must read and sign the procedures, to assist them with recognising forms of abuse and to take appropriate action. The member of staff on duty was clear about staff’s responsibilities to report poor practice. The service provider stated that the staff employed are not currently under any disciplinary action. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The property presents as a domestic dwelling and to fulfil its purpose, the property requires high levels of maintenance. There are repairs that must be undertaken to maintain a safe environment for the residents. Bedrooms are provided with sufficient furniture and fittings for residents to maintain their lifestyle. The communal space enables residents to gather together and share activities and for their private use. The ratio of toilets and bathrooms meet residents needs and offer personal privacy. The home is kept clean and free from unpleasant smells. EVIDENCE: Robleaze is situated on the Bath Road close to shops, amenities and bus routes. Originally two domestic dwellings adapted to provide accommodation and personal care to ten individuals. The property presents as a domestic dwelling, which blends with its immediate residential environment. While there is level access through the rear of the property, the home is not suitable for people that require equipment and aids, to maintain their independence. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 20 The property is Victorian and to fulfil the purpose of a care home, the building requires high levels of maintenance. While steps are taken to maintain the property, there are repairs that must be undertaken. It is evident from the tour of the premises that the following repairs are outstanding: In the bathroom the wire from the heater must be removed and the crack in the wall must be repaired. The carpet in the dining room requires cleaning, the border in a residents bedroom must be repaired/replaced. The framework and doors within the property also require attention. Accommodation is arranged over two floors, with bedrooms on both floors and shared space on the group floor. With the exception of one, bedrooms are single. There is a double room, which is currently used by siblings. Bedrooms contain furniture and fittings suitable to meet the individuals needs. The combination of the home’s furniture and personal belongings reflects individual’s personality and interests. On the ground floor there are two toilets and one bathroom and on the first floor there are two bathrooms and two toilets. The ratio of people sharing the toilet is 2:5, which is above the NMS. 2:2 is the ratio of people sharing the bathrooms. The number of toilets and bathrooms are above the NMS, offering sufficient personal privacy. There is a lounge, two dining rooms and a quiet area, for shared activities and private use. In the lounge the residents can sit together and watch the television, in the quiet area there is seating for four people. Six people sit together in one dining room and four in the other. Communal space available is sufficient for residents to share activities and for their private use. The laundry room is sited away from the kitchen. The floor and walls are tiled for easy cleaning. Within the laundry room COSHH substances are kept in a secure cupboard. There are two washing machines, one is specifically for sluicing soiled linen, and two tumble dryers. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. For the recruitment to be robust, application forms must seek full employment history from the candidate. When Request for Reference forms is used, the authenticity of reference must be sought. Staff attend training that ensures they have the skills to meet the changing needs of the residents. EVIDENCE: There are completed application forms for all the staff employed at the home. The application forms does not currently seek full employment histories from new staff. The service provider must review the standard application form to ensure the candidates full employment history’s is sought. Standard request for reference forms are used and the service provider must request further proof from the referee to establish their authenticity. This could be achieved through the use of an official stamp on the reference or compliment slips. Induction training is separated into five standards, based on Principles of care, The organisation, The role of the worker, Understanding the experiences of the needs of service users, Accommodation and Health and Safety. Foundation training follows from the induction programme and covers Promoting and Empowerment. Communication, Performance and Safeguarding adults. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 22 An annual training needs analysis is completed for each person and relates to individuals role. Training about keyworking, care planning, personal care, domestic tasks and report writing is analysed. Statutory training and NVQ qualification is also assessed. Distance learning is generally used by the home to provide Statutory, Foundation and Medication training. The home operates above NMS standards of 50 care staff to have NVQ leve2, seven staff is currently employed and five have completed vocational training. One person has NVQ level 2 and three have NVQ leve3. Residents gave feedback about the care through questionnaires and their comments indicate that staff always treats them well. It was understood from the service provider that staff would be attending external courses in Dealing with challenging behaviour and Autism training in the near future. This training will ensure that staff have the skills to meet the needs of residents that have the category of needs. Robleaze DS0000026552.V315189.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The acting manager, deputy and service provider are competent to undertake the day-to-day management of the home during the registered managers’ absence. The Quality Assurance system for the home must be further developed to ensure feedback informs planning and reviewing process of the home. Steps are in place to promote the safety of the residents and staff at the home. EVIDENCE: The registered manager will be resuming the day-to-day management of the home in January 2008. During this period of absence, the deputy is undertaking the role of acting manager, with the service provider. It was understood from the service provider that the acting manager and deputy have adequately maintained the day-to-day management of the home during the registered managers’ absence. Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 24 Residents questionnaires were used to seek their feedback about the environment, staff and food. Staff questionnaires also used to seek their feedback on the premises and their role. Surveys returned were then analysed and outcomes discussed and published. Feedback must be actively sought through individual and group discussion as well as satisfaction questionnaires. A review on the aims of the home must be conducted following the feedback analysis to then develop a plan of action. To further empower residents to give anonymous surveys the format used for questionnaires must be in a format that can be understood by the residents. The records that relate to fire safety checks and practices were examined and, indicate that practices and checks are conducted at the stipulated frequencies. Steps are in place through Health and Safety checks to ensure the safety of the residents and staff. Certificates are in place from contractors about the safety of portable appliances, fire systems, gas and electricity. Robleaze DS0000026552.V315189.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 x 2 3 3 x 4 x 5 x 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 x 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 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 1 x 3 x 2 x x 3 x Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 26 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. Standard YA20 Regulation 13 (2) Requirement For the safe administration of medication, one-person medication must not be used for another resident. The Quality Assurance system must be further developed to ensure that feedback informs the planning and review the quality of care at the home. Repairs must be undertaken to maintain a safe environment. The Complaints procedure must be in a format that can be understood by the people its intended. To fully safeguard the residents from abuse, the service provider must introduce those systems that monitor staff’s performance. (Supervision, performance monitoring, dismissal and referral onto the POVA list) a) Application forms must seek the individuals full employment history, b) The authenticity of the referee must be sought through the Request for reference forms. Timescale for action 30/10/06 2. YA39 24 30/03/07 3. 4. YA24 YA22 23 22 30/10/06 30/01/07 5. YA23 13(7) 30/12/06 6 YA34 7,9,19 Sch. 2.6 30/12/06 Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 27 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 Good Practice Recommendations Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Robleaze DS0000026552.V315189.R01.S.doc Version 5.2 Page 29 - 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!