Inspection on 25/05/07 for Southfields

This inspection was carried out on 25th May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southfields 11/01/07

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 Southfields 54 Southfield Road Gloucester Glos GL4 6UD Lead Inspector Mr Paul Chapman Unannounced Inspection 25th May 2007 09:00 DS0000067436.V336471.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 DS0000067436.V336471.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. DS0000067436.V336471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southfields Address 54 Southfield Road Gloucester Glos GL4 6UD 01452 545367 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.holmleigh-care.co.uk Holmleigh Care Homes Ltd Acting manager – Hazel Hatch Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000067436.V336471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2007 Brief Description of the Service: Southfields is registered to provide accommodation for up to seven people with learning disabilities. The home is a detached property in a residential suburb approximately two miles from Gloucester City centre. All of the service users have single bedrooms and these are situated over the first and ground floor. On the ground floor there is a communal lounge, dining room and kitchen. To the rear of the property is a substantial secure garden. Locally there are facilities including a shop, post office and pub that are used by service users. The home is staffed 24 hours a day, 7 days a week. The fees to live at the home range between £831.00 to £1600.00 per week. DS0000067436.V336471.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 at the home the people were eating breakfast and preparing to go out on a number of activities. The most striking difference since the previous site visit is improvement to the home’s environment. The proprietor has refurbished the majority of the building to a high standard. The only areas that still need to be addressed are peoples’ bedrooms, but this is planned for the future. A pre-inspection questionnaire was supplied prior to the inspection. Completed surveys were received from three people living at the home, one GP and one parent spoke to the inspector while they were at the home. Time was spent observing the care of people and their interactions with staff. The majority of people living at the home were spoken to and several people’s rooms were inspected on their invitation. The care of two people was looked at in depth including looking at their needs assessments, care plans, health care, activities and risk assessments. Four staff were interviewed about the care they provide. Other records examined included staff files and health and safety information. What the service does well: What has improved since the last inspection? DS0000067436.V336471.R01.S.doc Version 5.2 Page 6 Needs assessments, risk assessments and care plans have been completed for each person. The care plans written by the management team are detailed and allow staff to provide a consistent service to people while making needs assessments easier. Staff have completed training in safeguarding adults. The environment is now homely and comfortable. Speaking with staff team spirit appears to be better with staff appearing to be enthusiastic about their work. Staff files are well organised and allows for peoples training records to be examined easily. 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. DS0000067436.V336471.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 DS0000067436.V336471.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home do not have access to a Service User’s Guide explaining what service the home will/should provide. Each person has a statement of terms and conditions but they have not been signed and it cannot be confirmed that people agree with the terms and conditions. EVIDENCE: A requirement of the previous inspection report was that each person living at the home were given a copy of the home’s Service User’s Guide. The acting manager explained that this had not been completed although each person now had a copy of the home’s complaints procedure. Speaking with a person living at the home they confirmed they did not have a copy of the Service User’s Guide. The manager explained that an easy read version of the Service User’s Guide is currently being developed and will be given to each person when it is completed. Considering this information the requirement from the previous inspection will be carried over in this inspection report. DS0000067436.V336471.R01.S.doc Version 5.2 Page 9 It is impossible to make a judgement about the home’s assessment process for new people wishing to live in the home as no new people have been admitted since the previous inspection. A requirement of the previous inspection was to ensure that each person has a statement of terms and conditions signed by either the person living in the home or their representative. Examination of people’s files showed that these documents are now in place but have not been signed. The manager must now ensure that all of these documents are signed and this becomes a requirement of this inspection report. DS0000067436.V336471.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, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Needs assessments form the basis of the care plans developed by the home’s management team and this should ensure that peoples needs are met in the future. People are more empowered and enabled to make decisions about their lifestyles but recording is inadequate. Risk assessments are in place but are limited and put people at unnecessary risks. EVIDENCE: A requirement of the previous inspection report was to ensure that needs assessments were completed for all of the people living in the home. The manager and her deputy stated that assessments have been completed for all of the people in the home now. Two peoples care management files were examined in detail, both contained completed needs assessments that covered the following areas: • Education, training and occupation DS0000067436.V336471.R01.S.doc Version 5.2 Page 11 • Family and social contact • Assessment and management of risks • Communication • Cultural and faith needs • Physical and mental health • Specific conditions related to needs and specific input A requirement of the previous inspection was for the manager to then develop care plans to address these identified needs once the assessments had been completed. Each of the files examined contained care plans to address the needs highlighted by the assessment process. The manager and her deputy are to be commended for the detail provided in these care plans, as they will enable staff to provide care consistently, and allow for detailed reviews. Some shortfalls were identified that should be addressed, these include: • • Where completing a care plan may present a risk to a person the associated risk assessment should be linked to that care plan. Each care plan has a sheet attached to it that manager asks staff to sign confirming they have read and understood the care plan. This is a good practice but the manager must monitor them to ensure that all of the staff are signing these sheets as in the majority of cases only a small number of the staff team have signed them. The manager must ensure that people’s cultural needs are addressed in their care plans. These should include areas such as food, personal care and religion. Wherever possible people should be asked to sign their care plan agreeing with the actions and confirming their involvement in its development. • • One of the care plans examined was to address a person’s communication needs. Speaking with the manager and her deputy they stated that they had completed training in different forms of communication and that they had run workshops with the staff in communication. It is the aim of the manager that all of the team to complete formal training in communication in July this year. Some care plans were in place providing staff with guidelines on managing the behaviour that some people may display. See standard 23 for further detail. When speaking with staff they showed a good knowledge of the care plans that have been completed. Speaking with one person living at the home they said they had seen their care plans and that they had access to their file if they wished. DS0000067436.V336471.R01.S.doc Version 5.2 Page 12 The manager stated that it is their intention to implement Person Centred Plans (PCP) for each person in the future. This becomes a recommendation of this inspection report, as it will allow people to highlight their hopes and dreams for the future. A requirement of the previous inspection report was to ensure that people are empowered to make decisions about their lives and that records were available to support this. Observations during the site visit provided examples of people being asked what they would like to do, but records of this could be improved to provide evidence of when this happens. A requirement of the previous inspection report was to ensure that all of the people living at the home were given the opportunity to participate in the dayto-day running of the home. Since the previous inspection the manager has implemented weekly meetings. Minutes of these meetings showed that people are asked about activities they would like to complete, to decide on menus and whether they have any problems they wish to discuss. The two care management files examined in detail contained risk assessments for both people. Risk assessments for one person provided sufficient detail to minimise potential risks while they were completing a number of activities. Unfortunately the other file provided only a limited number of assessments which potentially may put that person at unnecessary risks. This was discussed with the manager. It becomes a requirement of this inspection report that this is addressed. People’s personal information is stored appropriately. DS0000067436.V336471.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People complete a wide range of activities that they choose to do and staff provide support to complete them where it is required. Staff support people to maintain relationships with their relatives. Menus are chosen by the people living at the home with staff support and advice about healthy diets. EVIDENCE: Speaking with two people living at the home they explained what activities they are involved in regularly. Both people said that they go out more now than they have previously. When asked what they do they gave the following examples of going to college, shopping, cinema, pubs, meals out and attending the organisations day service. Both people said some activities are completed as small groups but other activities are completed “one to one” with staff. One person said that they were going to the cinema with their key worker next week. In conversation with the key worker they confirmed this was to take DS0000067436.V336471.R01.S.doc Version 5.2 Page 14 place. Both people stated that they could have friends over to the home if they wished. People were seen following their interests and hobbies during the site visit. An example of this was a person drawing in the home’s lounge. Care plans and daily notes examined as part of the site visit provided further information of the activities people are involved in regularly. Some other activities that were identified as being completed include attending regular evening social clubs, attending music sessions and receiving massages from a qualified masseuse. The five staff interviewed as part of the site visit confirmed all of the activities that were taking place. Staff commented that they feel people go out a lot more than they used to and that they felt this was of real benefit to the people living at the home. On the day of the site visit 3 of the 5 people living at the home went shopping in Gloucester with staff support. In discussion with the management team they explained that one person wishes to start doing their personal shopping independently without staff support. It is planned that the person will be supported to achieve this in the future and a discussion took place about the strength of using a picture/photoshopping list. At the time of the site visit a parent of one of the person was visiting the home. They spoke briefly to the inspector saying that they were very satisfied with the care their relative was receiving. Speaking with people living at the home they agreed that their relatives are welcome to visit and that staff help them to maintain this contact where required. The management team at the home have recognised the need for people to be given the opportunity to develop skills and take responsibility. This is at an early stage of development at present. A good example is that they have started asking people to be involved in the preparation of food and taking part in cleaning around the home. One person said that they really enjoy being able to help with the food preparation. Staff commented that it has been really surprising to see peoples skills develop since this practice has started. Menus are chosen for the following week by people living at the home when they meet as a group each Friday. Menus showed that people living at the home are able to choose a wide range of meals and one person commented that they thought the food was really nice. Menus showed that the special dietary needs of ethnic minorities are addressed. DS0000067436.V336471.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans to address peoples personal care are thorough and detailed allowing staff to meet peoples needs. Peoples emotional and health needs are addressed by other professionals but health care assessments still need to be completed by the manager. People’s wishes regarding their increased mental and physical frailty have not been identified. EVIDENCE: The care plans seen relating to the personal care of people living in the home were very detailed. This enables people to be supported as they wish and consistently by the staff team. The detail in the care plan will allow staff to complete detailed reviews of people’s skills and identify where skills are being maintained, developed or deteriorated. The files examined by the inspector provided evidence of other professionals being involved in the physical and emotional care of people living at the home. DS0000067436.V336471.R01.S.doc Version 5.2 Page 16 Files seen contained “OK Health checks” (identifies peoples medical needs) for each person. The manager must ensure that each of these documents is completed thoroughly. A requirement of the previous inspection was that peoples’ wishes relating to increased mental and physical frailty were identified. This has not been achieved and is carried over as a requirement of this inspection report. The homes medication system was not inspected on this occasion and will be subject to an unannounced inspection by one of the CSCI’s specialist pharmacist inspectors. DS0000067436.V336471.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person has a copy of the complaints procedure but the manager must ensure that each person is able to use it if they need it. The current behaviour management plan is out of date and contains poor terminology that must be reviewed. Although other people may display behaviours that challenge there were no care plans to meet their needs and this puts both people living at the home and staff at unnecessary risk. EVIDENCE: The files examined by the inspector contained a copy of the home’s complaints procedure in an easy read format. The manager stated that all people living at the home have access to this document. Speaking with a person they said that if they were unhappy they would speak to the manager. It is recommended that the manager ensure that the complaints procedure is explained to all of the people living in the home. A requirement of the previous inspection was to ensure that all of the staff had completed training in safeguarding vulnerable adults. Training records examined provided evidence that this had been completed. A number of the people living in the home sometimes display behaviour that may challenge. The CSCI have been concerned by some of the practices of previous staff working at the home when they are managing this behaviour. All of the staff spoken with were asked about how they manage a specific person’s DS0000067436.V336471.R01.S.doc Version 5.2 Page 18 behaviour at these times. All of the staff gave answers that showed a consistent approach when working with the person, and that staff had a good knowledge of good working practices. Examining the person’s care plan relating to their behaviour management the inspector identified some practices that were no longer followed and some poor terminology that must be reviewed. This was brought to the attention of the management team. The management team were open with the inspector and explained that currently these are the only detailed behaviour management plans. The need to ensure that behaviour management plans for the other people living at the home was discussed and it was agreed that this would be addressed quickly. This becomes a requirement of this inspection report. DS0000067436.V336471.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home has been completely transformed by the renovations, people living at the home are benefiting from a more homely, comfortable environment. EVIDENCE: Since the previous inspection the home has been extensively renovated both inside and out. A number of areas have been addressed: • • • • The front of the home has been freshly painted. The kitchen has been replaced (including floor and wall tiles). The lounge has had French windows fitted and has been decorated in light colours. New bathrooms have been fitted throughout the building (this also includes creating new bathrooms). DS0000067436.V336471.R01.S.doc Version 5.2 Page 20 • • New carpets have been fitted in all communal areas. New furniture has been bought and installed in the lounge and dining room. The home’s proprietor is to be commended for improvements made to the home’s environment which now provides the people with a high quality and comfortable environment. The manager stated that it is planned that a new conservatory will be fitted to the rear of the property in the near future. The home has substantial grounds to the rear and the manager explained that they have arranged for someone to come in and create a sensory garden. As part of the refurbishments two people have moved into bedrooms on the ground floor. Both of these bedrooms were seen, and have also been decorated to a high standard. The manager stated that the next step in the home’s refurbishment is the re-decoration of people’s bedrooms (if that’s what they want). The inspector spoke to the deputy manager about ensuring that people living at the home are empowered to choose the colours and styles of their bedrooms. The deputy manager explained that one person who is a talented artist is going to be involved in decorating their bedroom. Others will be given colour charts to enable them to choose what colours they would like. At the time of the site visit the home was clean and hygienic. DS0000067436.V336471.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Records provide evidence that staff receive training to meet the needs of the people living at the home. The CSCI is unable to confirm that all of the staff have completed CRB’s as disclosures were not present in the staff files. Staff have started to receive supervision sessions with the manager and this helps to provide a consistent approach to the people living in the home. EVIDENCE: A requirement of the previous inspection was to ensure that training records were available for all of the staff employed in the home. At this site visit certificates were available to provide evidence of the training completed since the previous inspection. In addition to seeing what training had been completed a programme for training up to July was available. It showed that staff were offered training in Equality and Diversity, Understanding Autism, Safeguarding Adults, Moving and Handling, First Aid, Epilepsy and Food hygiene. As identified earlier in this report in addition to this staff will be completing training in communication. Records of the completed training show that staff are receiving training to meet the needs of the people living in the DS0000067436.V336471.R01.S.doc Version 5.2 Page 22 home. All of the staff spoken with commented that they thought the training they had received in the past 6 months has been excellent. A requirement of the previous inspection was for the home to ensure that staff recruitment records were available for inspection. Four staff files were examined in detail. Each file contained a completed application form, references, a form of identification and a contract. One person had a Criminal Records Bureau Disclosure (CRB), whereas other files contained memos from the organisations HQ giving the CRB disclosure number. The disclosure number is insufficient and the CSCI must be able to examine the original document. It becomes a requirement of this inspection report that CRB’s for all of the staff employed in the home are available for inspection. The acting manager has been in post since March this year. Staff files showed that each member of staff had received one supervision session with the manager since that date. Speaking with staff during the site visit they all agreed that they found supervision really useful providing them with the opportunity to discuss any issues and resolve problems. DS0000067436.V336471.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a service that is well run and a manager that is committed to improving the service provided at the home. There is no quality assurance system in place that allows for regular review of the quality of the service. EVIDENCE: Since the previous inspection the acting manager has been replaced with another acting manager. The new acting manager started at the home in March this year. The deputy manager has remained unchanged throughout this DS0000067436.V336471.R01.S.doc Version 5.2 Page 24 time and this has enabled some consistency throughout the recent months. Both the acting manager and her deputy have worked hard to complete the needs assessments and develop the care plans and are obviously committed to improving the quality of the service provided at the home. Staff commented, “The acting manager has turned the place around”. The acting manager is in the process of applying for registration with the CSCI. It becomes a requirement of this inspection report that this process is completed. The previous inspection report made a requirement that the home must have a quality assurance system that puts the views of the people living at the home as central in the process. The acting manager highlighted the weekly resident meeting as a good forum for people to discuss issues about the service offered by the home. In addition tom this they intend to use a question that people can complete. Other methods of quality assurance were discussed including the use of regular audits of food and activities as well as the use of questionnaires with other professionals and relatives. The requirement of the previous inspection report is carried over as part of this inspection report. Examination of health and safety records provided the following evidence: • Fridge and freezer temperatures were recorded twice daily. • A fire risk assessment was completed in January 2007. • A number of gaps were present in the safety checks of the fire equipment. • A fire drill needs to be completed at night. • Portable Appliance Testing had been completed. • COSHH data sheets were available for the chemicals used in the house. The acting manager must ensure that fire safety checks are completed as prescribed by the relevant regulations. This becomes a requirement of this inspection report. DS0000067436.V336471.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 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 3 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 2 X 1 2 X 2 X X 2 X DS0000067436.V336471.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 YA1 Regulation 5 Requirement Timescale for action 27/07/07 2. YA5 5 (1) b 3. YA6 15 All of the people living at the home must have a copy of the Service User’s Guide. This is to ensure people have access to the relevant information about the home. Previous timescale not met 02/03/07 Either the person, or their 29/06/07 representative must sign each person’s statement of terms and conditions. Previous timescale not met 30/03/07 The registered person must 29/06/07 ensure that people’s identified needs are addressed in their individual care plans. People must be empowered to make decisions about their lives and records should be kept evidencing this. People must be given the opportunity to participate in the day-to-day running of the home. Risks to people must be assessed, minimised and DS0000067436.V336471.R01.S.doc 4. YA7 15(2) c 29/06/07 5. YA8 16(2) m 29/06/07 6. YA9 13 (4) b, c 29/06/07 Version 5.2 Page 27 7. YA19 12, 14 8. YA21 14, 15 9. YA23 15 managed appropriately to enable people to live fulfilling lifestyles. Previous timescale not met 30/03/07 People’s health needs must be assessed. Previous timescale not met 30/03/07 People’s wishes relating to ageing and illness must be identified and care plans written to meet people’s needs. Previous timescale not met 27/04/07 The behavioural management plan highlighted in the body of this report must be reviewed. Behavioural management plans must be developed for each person who may display behaviour that challenges. Criminal records Bureau disclosures must be available for inspection by the CSCI. An application to become a registered manager must be submitted to the CSCI. A quality assurance system that puts the views of the people living in the home as central in the process must be developed. Previous timescale not met 27/04/07 Risks to people should be minimised through fire safety equipment being checked regularly by staff. 27/07/07 27/07/07 29/06/07 10. YA34 7, 9, 19 schedule 2 8(2) 29/06/07 11. YA37 29/06/07 12. YA39 24 27/07/07 13. YA42 13(4) 29/06/07 DS0000067436.V336471.R01.S.doc Version 5.2 Page 28 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. 2. 3. Refer to Standard YA6 Good Practice Recommendations The manager should ensure that Person Centred Plans are introduced for each person living in the home. Key workers should go through the complaints procedure with each person. The manager should ensure that each person has the opportunity to decorate their bedroom if they wish. YA22 YA25 DS0000067436.V336471.R01.S.doc Version 5.2 Page 29 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 DS0000067436.V336471.R01.S.doc Version 5.2 Page 30 - 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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