Inspection on 18/09/06 for Russell House

This inspection was carried out on 18th September 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Russell House 12/10/05

Russell House 06/04/05

Russell House 30/11/04

Russell House 19/07/04

Russell House 16/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Russell House Hortham Lane Almondsbury South Glos BS32 4JH Lead Inspector Paula Cordell Key Unannounced Inspection 18 September 2006 09:45 th Russell House DS0000020286.V304647.R02.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 Russell House DS0000020286.V304647.R02.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. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Russell House Address Hortham Lane Almondsbury South Glos BS32 4JH 01454 619131 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mrs Sousan Asef-Evans Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 6 persons with learning disabilities and physical disabilities who are receiving nursing care. Staffing Notice dated 13/10/1997 applies Manager must be a RN on Parts 5 or 14 of the NMC register Date of last inspection 12th October 2005 Brief Description of the Service: Russell House is a care home registered to provide personal care and nursing care to six people with a physical and a learning disability. The home is situated in a rural location off the A38 in Almondsbury and has its own mini bus, which, is essential to provide access to the local social and community venues. The home is set in its own grounds. There is an extensive garden with a patio area, which provides level access for residents. Car parking is available. The home is a converted property and all accommodation is provided on the ground floor. This comprises of two single rooms and two double rooms. Whilst none of the rooms have ensuite facilities all rooms have a washbasin. Communal rooms include a lounge, dining room and a multi-sensory area. The bathroom and toilet areas have been fitted with adaptations to meet the care needs of the residents in the home. Appropriate equipment is provided for individual use based on the assessed identified need. The fees at the time of compiling this report were in the region of £1,1101,400. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The purpose of the site visit was to review the progress to the requirements and recommendations made at the last visit in October 2005 and review the quality of the care provided for the residents living at Russell House. The focus of the site visit was on the general care of a sample group of residents and the environment, including an extensive tour of the premises. This provided a good opportunity to observe residents as well as allowing for informal conversations with the staff supporting them. Three members of staff were spoken with during the inspection, which included the registered manager. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the residents. These were used as a focus for the site visit along with the pre-inspection questionnaire completed by the home and the monthly provider reports. The site visit was conducted over a period of 4.5 hours. Please note that due to the profound and multiple disabilities, residents are unable to verbally communicate their views about the home. However, opportunities were taken to observe individuals and it was evident that staff have developed effective ways of communicating with residents which has been built over a period of time. What the service does well: What has improved since the last inspection? Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 6 Residents have benefited from the flooring in communal areas being deep cleaned. Residents now benefit from staff that feel supported in their role and receiving regular supervision. 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. Russell House DS0000020286.V304647.R02.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 Russell House DS0000020286.V304647.R02.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): 1,2,3,4,5, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents assessed care needs were being met. EVIDENCE: The home has a statement of purpose and a service user guide. This was seen at the last site visit and met with the National Minimum Standards and the Care Home Regulations. There was an assessment of need for each resident, which was being kept under review. This included an assessment and a care plan drawn up by the placing authority and other professionals involved in the care of the individual. The home has a clear admission procedure, which includes supporting individuals to visit the home prior to making a decision and a trial period. Many of the individuals living in Russell House have lived there for many years since it first opened fifteen years ago with the last admission being five years ago. It was evident that the home was meeting the assessed care needs of the individuals living in Russell House. Staff had received training appropriate to the care needs of the residents. Russell House DS0000020286.V304647.R02.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. Residents each have a plan of care, which reflects their changing needs and personal goals. Risk assessments were in place to ensure the safety of the individuals. EVIDENCE: Care plans were seen for two of the six residents. These were informative and tailored to the individual giving clear instructions for staff to follow. Photographs had been used to assist with manual handling equipment and for passive exercises. This is commendable. Care plans had been kept under review meeting the changing needs of the residents. Care records included a communication dictionary for each resident detailing how an individual uses non-verbal communication to effectively get their needs across. A member of staff confirmed that they had read the plans as part of the induction process. Staff were observed supporting individuals to communicate effectively and responding appropriately to resident’s body language. This is good practice. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 10 Risk assessments were in place relating to individual residents and these had been kept under review. Residents were involved in day-to-day decision processes including menu choice, what to wear and where to spend time in the home. More complex decisions were made by the staff due to the nature of the individuals and their dependence on staff for all areas of their care. Records included observations from staff on whether an activity was enjoyed. Staff spoken with described how residents would respond if unhappy and whether they did not want an activity to continue. It was evident that the staff would act appropriately. Evidence was provided that advocacy has been used to increase day care opportunities for one individual. The manager stated that whilst no advocacy service is being used at present they would be no hesitation for referrals to be made. From reading care records and letters it was clear that the staff actively advocate for residents. This was evident where staff are writing letters to the Trust advocating that residents should have a single bedroom which affords them their own privacy in relation to the delay on the refurbishment. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents have opportunities for personal development and accessing the community. A healthy diet is available to individuals living in the home. EVIDENCE: Care plans included information on how the person would like to spend their time and the important people in their lives. Residents had a combination of structured activities including for one individual attendance at a local day centre. Other activities included hydrotherapy, access to a trampoline session, aromatherapy and reflexology. Residents have experienced an annual holiday over the last twelve months with further trips being organised over the next couple of months. Two of the residents went on an activity holiday not long after the last site visit. It was evident from photographs, the diary of events and an article in the Trust’s Newsletter that this had been successful and enjoyable for the residents and Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 12 the supporting staff. From conversations with the manager and the staff holidays would be tailored to the individuals. It was evident from talking with staff that residents would be supported to pursue different activities and that their physical disability would not hinder or prevent them. The home is supported by a team of community day care workers who assist in the planning of the social activities. It was evident residents were getting out in the local community at least twice a week. The manager was exploring other options to increase this and purchasing additional hours for specific residents. The home has a mini bus, which is funded by the residents including the dayto-day running costs. Information on the funding arrangements was included in the individuals contract and the Trust’s policy describing the arrangements for covering the petrol. The cost of the vehicle is particularly high. This has been assessed as a necessity, due to the rural location of the home and the need for additional specialist equipment to enable residents to access the community. Activities were organised in house including gentle exercises, relaxation and listening to music. An area in the home has been set-aside as a relaxation area and includes specialist equipment. Staff have been creative in making this area comfortable. It was noted that bedrooms have some sensory and relaxation equipment. This is good practice. Menus were sent to the Commission for Social Care Inspection prior to the site visit. These provided sufficient evidence that residents had available to them a wholesome and varied diet. The home employs a cook who has recently completed an NVQ 2 in catering. Care plans included information on how individuals like to be supported during meal times. Staff supported individuals at the dinner table discreetly and sensitively. The meal was unrushed and the atmosphere relaxed. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s personal and health care needs were being met. Safe systems were in place for the administration of medication. EVIDENCE: Records were informative about the personal care needs of individuals giving clear direction to staff. This included individual preferences on how they wanted to be supported. Residents are supported to attend appointments with the GP, opticians, dentist and hospital. In addition the community learning disability team were involved including speech and language professionals. Residents nursing care needs are being met. Registered nurses support residents at all times. The staff rota provided evidence that a registered nurse staffs the home 24 hours a day in accordance with the home’s certificate of registration. The home is registered to provide nursing care. The home has good management of prevention of pressure sores. This includes guidance for staff in the form of training, a local policy and individual risk assessments and equipment to prevent skin breakdown including special seating, pressure relieving mattresses and evidently good personal care. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 14 There were clear records on how residents are to be supported in relation to manual handling to ensure that this is done safely. The manager is a manualhandling assessor and arranges periodic updates with her staff team. This is good practice. A member of staff confirmed that manual handling equipment had been discussed during the induction period with a period of shadowing to ensure the individual was competent and confident. This is good practice. On the day of the inspection staff responded to the care needs of the residents in a sensitive and patient manner. Personal care was administered in the privacy of the individual’s room or the bathroom behind closed doors. Residents who share bedrooms have curtains providing them with their own personal and private space. Staff were seen knocking on doors before entering. This is good practice further evidencing that the culture of the home includes maintaining resident’s privacy and dignity. Residents are supported daily with their personal care needs. Residents had very distinctive style in clothes and haircuts. Residents seen on the day of the inspection had the appearance of being well cared for. Medication was satisfactory. The home has developed medication risk assessments and protocols for each individual involving the doctor. This included a home remedy protocol for each individual. This is good practice. The information was informative and detailed to enable new staff to support individuals. The registered nurses are responsible for the administration of medication. Each staff member has been assessed as being competent in the administration of medication. Records were in place and were periodically reviewed. There is a rolling training programme with the local pharmacist on medication. Certificates were seen of attendance. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are robust procedures in place for the protection of the residents living at Russell House. Staff have built good relationships with residents and have an understanding to interpret if individuals are unhappy. EVIDENCE: The home has a complaints procedure, which had been viewed at the last inspection and met with the legislation and National Minimum Requirements. A pictorial leaflet is available which is in an accessible format. In this particular home it is difficult for residents to make verbal complaint due to their degree of physical disability. However, the staff in the home had a good knowledge of the residents and their preferences. However, it was difficult to fully judge how the home would respond to a complaint. The home has not had a complaint made about the service since the manager commenced in post, in June 2004. However, the home has made a formal complaint on behalf of a resident to an external service. This further demonstrated that the staff act as advocates for the individuals living in the home ensuring that individuals care needs and aspirations are met. The home’s record demonstrated that there have been three complaints in the last twelve months but this does not directly relate to the service provided. One is made to the organisation on the delay in the proposed build to the organisation advocating the benefits of individuals having their own bedrooms and private space. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 16 Training records demonstrated that the majority of the staff had attended a protection of vulnerable adults alerter course. The Trust has a policy for dealing with allegations of abuse. A bank (relief) staff stated that this had been covered during their induction, and could recall the procedure and had no hesitation evoking the procedure should an allegation of abuse becomes apparent. The home has robust procedures on the finances of the home and that belonging to residents. These procedures were translated into practice. Staff were observed completing checks on the finances during the handover. Two staff signatures and a receipt supported all expenditure. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a safe, homely and comfortable environment. Residents would benefit from having a bedroom of their own. EVIDENCE: Russell House is in a rural location. There are two single bedrooms and two double bedrooms. The Trust is in the process of liaising with the social landlord to refurbish the home to enable residents to have a single bedroom and increase the numbers of beds from 6 to 8. The manager stated that the plans are still being discussed and the home is awaiting the outcome. It was evident that providing single bedrooms is the way forward giving residents more privacy and ensuring the home meets the National Minimum Standards. It is strongly advisable that where a vacancy occurs in a double room that a new resident is not admitted into a shared space unless for married couples or individuals expressing a clear wish to share and this would need to be demonstrated. Maintenance was being responded to appropriately ensuring a safe place for residents to live. Staff maintain monthly audit reports on the environment Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 18 including equipment and the general upkeep. It was evident that any deficit would be reported to the Trust. The Trust has a property manager who has ultimate responsibility for the major expenditure. All areas of the home were clean and free from odour. The staff are commended on the upkeep of the garden which has been stocked with flowering shrubs and is a nice space for residents to sit and relax. Residents were observed sitting in the garden on the day of the inspection with members of the staff team. Again the staff are commended on the recent purchase of pictures, plants and the new seating which has enhanced the homely feel to Russell House. The home has responded to a previous requirement to ensure that all carpets in communal areas are deep cleaned. Residents have one useable bathroom available to them. This area was lockable and there was a safety device if necessary. The home has policies and procedures on infection control and individual guidelines in care plans. There was a supply of plastic gloves, aprons, liquid soap and paper towels in toilets and in bedrooms. All residents require assistance with their mobility and personal care. There are a number of aids and adaptations including hoists, high low bath and beds that could be raised to assist an individual with a physical disability. Records seen confirmed that an external contractor maintained these periodically. Records seen confirmed that staff had attended training in manual handling. There were clear instructions in care files tailored to the individual on the equipment in use. This is good practice. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 19 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): 32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Competent and trained staff support residents. The home is adequately staffed to meet the care needs of the individuals. EVIDENCE: The duty rota provided sufficient evidence that the home was staffed adequately to meet the assessed care needs of the residents. Recruitment information was available for staff case tracked. There were good recruitment procedures in place to ensure the safety and protection of the residents, from initial advert through to interview, and ensuring all documentation is in place prior to commencing in post. It was evident from records and conversations with staff that there were good support mechanisms in place including regular staff meetings and daily handovers and supervisions. Documentation was in place to support this. The home has responded to a recommendation from the previous site visit to ensure that staff receive regular supervisions at least six per year. Staff training was in place and covered a wide range of topics relevant to the care of the individual residents. There was a good rolling programme of health Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 20 and safety training for all staff. Staff complete the Learning Disability Award Framework as part of their induction. It was evident that the home was working towards the government target of 50 of the workforce having an NVQ in care unless they hold a registered nurse qualification or equivalent. Records confirmed that qualified staff are maintaining their registration with the Nursing Midwifery Council (NMC). Staff spoken with during this site visit had a good understanding of the care needs of the residents. Observations of the interactions between the staff and the residents were that positive relationships had been built. Residents appeared relaxed and settled with staff. Russell House DS0000020286.V304647.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from a well-managed service, where there is a review of the provision of service to ensure that a quality service is provided to the individuals living in the home. However, health and safety risk assessments must be kept under review to ensure are current and safeguard both the individuals living in the home and the staff team. EVIDENCE: Mrs Asef-Evans manages the home. She is passionate about her role as manager and the rights of the individuals living in the home to an individual tailored lifestyle. Mrs Asef-Evans has since the last site visit completed the Registered Manager’s award (NVQ 4). She is an NVQ assessor. Mrs Asef-Evans demonstrated a good understanding of the service users living in Russell House and has formulated a plan on what needs to be addressed to ensure that the home runs smoothly and meets the National Minimum Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 22 Standards. Staff spoken with spoke positively about the support and the open approach of the manager. There was evidence of regular staff meetings covering a wide range of topics including development of an action plan. The home is in the process of implementing a quality audit, which seeks the views of relatives, visiting professionals and the residents. The plan is for this to commence in October 2006 and shall be reviewed and monitored at the next site visit. In addition the home completes a variety of audits on the environment, care planning processes, supervisions, team meetings and safe systems of working including the monthly provider visits in respect of regulation 26. The Commission for Social Care Inspection are receiving copies of these reports. Policies and procedures are in place to ensure the health and safety of the residents and staff members, as seen at the last inspection. These form part of the induction. Regulation 37 notifications are being received on a regular basis in the event of any incident occurring in the home that might adversely affect the residents. Records were held securely and found to be current and up to date. There was a current certificate of insurance displayed in the home. From discussions with staff and staff training records it was evident that there is a rolling programme of health and safety training including manual handling, fire, food hygiene and first aid. From conversations with a bank member of staff they had recently completed these as part of their induction. The home has guidance on infection control and policies to ensure the safety and well being of residents and staff. Risk assessments were in place demonstrating that there were safe guidelines for staff and service users on a number of activities that are undertaken in the home and the community. These had not had a formal review in the last twelve months. There were good routine checks on the property and equipment to ensure the safety of residents and staff. Fire records were current demonstrating that staff attend periodic training and drills as prescribed by the fire officer and checks were being completed on the fire equipment. There was a fire risk assessment in place however this had not been formally reviewed since February 2005. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 x 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 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 3 x 3 3 3 3 3 2 x Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 24 Yes 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 YA42 Regulation 13 (4) Requirement To keep the health and safety risk assessments under periodic review including fire risk the assessment. Timescale for action 18/11/06 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 YA25 Good Practice Recommendations Double rooms where a bed becomes vacant that the vacancy is not filled to provide the remaining occupant with his or her own private space. Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 25 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 Russell House DS0000020286.V304647.R02.S.doc Version 5.2 Page 26 - 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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