Inspection on 23/07/08 for The Mendips

This inspection was carried out on 23rd July 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

The Mendips 14/07/09

The Mendips 12/07/07

The Mendips 12/07/06

The Mendips 14/02/06

The Mendips 29/09/05

The Mendips 16/02/05

The Mendips 01/07/04

The Mendips 10/03/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 The Mendips 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL Lead Inspector Sandra Jones Key Unannounced Inspection 23rd & 25th July 2008 09:30 The Mendips DS0000026568.V365071.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 The Mendips DS0000026568.V365071.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. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mendips Address 2-3 Shamrock Road Upper Eastville Bristol BS5 6RL 0117 9518548 0117 9518548 s_ghamy@hotmail.com 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) Mr Mamode Raschid Ghamy Mrs Bibi Ghamy & Mr M R Ghamy Mrs Bibi Ghamy & Mr M R Ghamy Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (9) The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 9 persons with mental disorder aged 30 years and over 12th July 2007 Date of last inspection Brief Description of the Service: The Mendips is operated by Mr and Mrs Ghamy, it is a registered care home for nine adults with mental health care needs, aged 30 years and over. The home is situated close to the Fishponds Road and is within walking distance of shops, library, places of worship and other amenities and bus routes. The property has the appearance of a domestic dwelling and blends well with its local environment. The fees range from £334.00 - £533.54 per week. Items not included in the fee include dry cleaning chiropody, clothing and hairdressing. Currently prospective residents are given this information verbally. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key inspection was conducted unannounced over two days in July 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection. This information was used to plan the inspection visit. “Have your say” surveys were sent to people living at the home, those with an interest into the home and health care professionals. Four people living at the home, one relative and two health care professionals responded through surveys in advance of the inspection. There are eight individuals living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: The following comment was made by a relative through surveys about what the service does well, “The care home is open to the needs of the family and its culture.” While four people refused to make comments about the home, the following statement was made. “ I am grateful for what Mr Ghamy does, he works hard and is making the environment homely.” People at the home said that the staff treated them well, they have the skills to meet their needs and know whom to approach with complaints. The Mendips DS0000026568.V365071.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. The summary of this inspection report can be made available in other formats on request. The Mendips DS0000026568.V365071.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 The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The admissions procedure in place enables people wishing to live in the home to make an informed choice about moving there. They can be reassured that the home will have the skills and resources to meet their assessed needs. EVIDENCE: The prepared Statement of Purpose defines the home’s philosophy, which is to provide a secure, relaxed and homely environment where care, wellbeing and comfort are the prime importance. The admission process that will be followed for people wishing to live at the home is outlined in the Statement of Purpose. The criteria for admission is listed and confirms that introductory visits are encouraged and trial periods are offered. These steps will ensure that staff have the skills and appropriate resources are available for people wishing to live at the home. There were no admissions to the home since the last inspection. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 9 The four adults that responded through surveys said that they were asked if they wanted to move into the home and they got enough information about the home before moving there. The relative that responded also confirmed that enough information was provided about the home to make decisions about the home. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. The care planning systems must be further developed to provide an effective system where individuals benefit from receiving an individualised and consistent service. They can expect to be involved in making decisions about all aspects of their care. EVIDENCE: There are eight people currently living at the home and the case records of four people were used to check the care planning system in place. There is a combination of needs assessments provided by the Local Authority, for some there are needs assessments compiled by the social worker and for others there are Individuals Care Planning Approach (ICPA) plans in place. From the care plans provided by the Commissioners, a home’s care plan and associated risk assessments are then developed. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 11 It is evident that a person centred approach is being introduced and to further develop this approach action plans must include individual’s likes, dislikes and preferred routines. The service provider said that the care plans are based on the individual’s choices and routines. While it is accepted that staff have specific knowledge of the person, the information is not clear. For example, instead of using such terms such as encourage and prompt, the guidance must be more specific, so that individualised and consistent care can be provided. The home is registered to provide accommodation and personal care to people with mental health care needs. Risk assessments are used to describe the individual’s mental health care need. The triggers that the individual’s mental health is deteriorating and the actions that staff must take to meet the need are not currently part of the action plan. Triggers, signs and symptoms of a deteriorating mental health must be included within the risk assessments. This will ensure that staff can monitor individuals mental health and where appropriate seek specialist support for the person. A member of staff on duty was consulted about their responsibility towards the care planning process. It was stated that a keyworker system is not in operation because it’s a very small staff team and they all have specific knowledge of the person. Regarding care plans, it was understood that staff make suggestions and read the care plans to ensure the information included is accurate. Surveys from a relative’s state that the home meets the needs of their relative living at the home. It is evident from the records that two individuals at times exhibit aggressive and violent behaviours. The home’s approach is to diffuse the situation and strategies instruct staff to sensitively move others away and to inform the service provider. The triggers and safeguarding procedures that will be followed must be included within the strategies. This will ensure that individuals are safeguarded from abuse and staff can consistently manage potentially aggressive and violent situations. One person currently living at the home, may at times abuse alcohol and, the care plan states that the person must be discouraged from “binge” drinking. A risk assessment that supports this need must be developed, so that members of staff are guided on the actions to be taken to meet the goal identified. Possible triggers and the agreement of the person must form part of the risk assessment. The manager said that the people at the home are able to make their own decision. The current staff have attended Mental Capacity Act training to increase their awareness about enabling people to make decisions. The manager said that the benefits of the training has ensured that staff work The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 12 within the Code of Practice and that people can be supported by an IMCA to make decisions. The member of staff on duty was consulted about their responsibility towards empowering people to make decisions. It was stated that people are supported to make decisions and there are times when these individuals are more able to make decisions that other. The Mendips DS0000026568.V365071.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 (adequate) This judgement has been made using available evidence including a visit to this service. The support systems in place for individuals are adequate and overall individuals are active and valued members of the community. EVIDENCE: As previously mentioned within the body of this report, a person centred approach to meeting needs is being developed and activities and hobbies form part of the approach. Information regarding activities and hobbies are sought from the person and included in their care plan. Care plans must be more specific about the activity to be provided, when the activity is to take place and with whom. Running reports show that people at the home are undertaking activities outside the home. For example, people at the home are going to the gym and the park with staff. This is a recent change in the way care is being delivered and must continue to be developed. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 14 The person consulted about activities provided stated that reading newspapers and listening to classical music are the ways they choose to spend their day. The four people that responded through surveys said that they are able to make decisions about what to do each day. Four people are independent in the community and four need staff support. Entries in the daily reports indicate that the staff support individuals to participate in local events, visit parks and go grocery shopping. The member of staff on duty agreed to feedback about the staff responsibility towards social inclusion. The member of staff said that the staffing arrangements were changed so that staff could accompany individuals out of the home. The home acknowledges that maintaining contact with family and friends is important. For this reason visitors’ are welcome at all reasonable times and the visitors book show that individuals relatives visit the home. The relative that responded through the survey said that the home assist their relative at the home to keep in touch with them. The Statement of Purpose confirms that staff are trained to respect individuals rights. Privacy and Dignity are included in core values of care, which contribute to the philosophy of the home. Rules regarding smoking, pets, and alcohol exist at the home and are specified within Statement of Purpose. Smoking is permitted in the designated areas, pets and alcohol are not permitted in the home. The member of staff was consulted about the way people living at the home are respected as individuals. The member of staff said that seeking consent before undertaking personal tasks, knocking on doors and speaking to individuals with respect are the ways people are respected. It was also stated that although there was a washing-up rota, there is no expectations from individuals to participate in household chores. The person consulted about the way they are treated as individuals said that they are treated well by the staff, they respect their rights in particular to privacy and dignity. It was also stated that staff address them correctly. A record of food provided is maintained and indicates that people at the home have a varied diet. People at the home generally have a continental style breakfast, a cooked lunch and tea. The service provider said that there are limited amounts of fresh, frozen and tinned foods stored at the home because provisions are purchased daily. The member of staff on duty said that there is always a choice of meals and before each mealtime individuals are asked for their choice of meal. It was also confirmed that cultural meals are provided. The person giving feedback about the home said there is enough to eat and the meals served are hot, which is preferred. The Mendips DS0000026568.V365071.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) & (20) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Personal care is included in the care planning process and while the need is identified, action plans that are person centred must be developed. The member of staff giving feedback about the standards of care at the home confirmed that four people are supported with personal care. The individuals at the home are registered with a local GP and they have access to NHS facilities. Members of staff currently accompany six people on health care visit and daily reports from the staff illustrate that people visit GP’s and have hospital appointments. Individuals visit the dentist, chiropodist and optician and documentation supports that people have input from health and social care professionals. One person living at the home confirmed that The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 16 specialist support is sought. It was stated that an assessment is taking place for a wheelchair to ensure their independence in the community. The member of staff on duty said that individuals are accompanied on GP’s visits, check-ups, and reviews. Daily reports and handovers are used to pass information from shift to shift, which ensure that advice is followed. The Health care professional that responded through surveys said that the staff demonstrate a clear understanding and meet the care needs of the people at the home. The relative said through the survey that the home keeps them informed about the important issues affecting their relative at the home. The service provider said that two people need support with walking from the staff. To maintain these individuals level of independence with moving around the home, handrails were installed. Moving and handling risk assessments were reviewed for these individuals and require additional information. Consideration must be given to structuring risk assessments so that it lists when assistance is needed, the number of staff that must assist along with the equipment and the support needed. Medications are administered from standard packaging by the staff and records of administration are signed after they are administered. The service provider said that the home does not use one specific pharmacist. This must be considered so that people at the home can benefit from a consistent service. A record of medications no longer required is maintained which the pharmacist signs to indicate receipt of the medication for disposal. The Mendips DS0000026568.V365071.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 (good,) This judgement has been made using available evidence including a visit to this service. Individuals can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaints procedure is included within the Statement of Purpose. The procedure confirms that complaints will be taken seriously, investigated and the complainant will be informed about the outcome. There were no complaints received at the home since the last inspection. An individual giving feedback said that Mr Ghamy would be approached with complaints. Surveys from people at the home and their relative’s state that they know how to make complaints and who to approach with their complaints. The member of staff on duty was asked about the way individuals are supported to make complaints. It was stated that complaints from individuals would be passed onto the service provider. The home has an Abuse policy, which underpins the commitment towards safeguarding individuals from abuse. The factors of abuse and the actions to be taken where alleged abuse to occur is included. The service provider must The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 18 review the procedure and make the necessary amendments so that it follows “No Secrets” guidance. The service provider said that there are no outstanding Safeguarding Adults referrals. The member of staff was consulted about their responsibility towards safeguarding individuals from abuse. The member of staff said that Safeguarding Adults training was attended and that there are “No Secrets” procedures available at the home. Additionally, staff said that where abuse to occur, the procedure would be followed to ensure that appropriate action would be taken. The person at the home said that they felt safe at the home. The Mendips DS0000026568.V365071.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) & (30) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The people at the home benefit from living in a comfortable and clean environment. EVIDENCE: Two terraced properties were originally converted to offer accommodation to nine adults with mental health care needs. The property of the service providers adjoins and can be accessed through the care home. It has the appearance of a domestic dwelling, which blends well with its immediate environment. It is within walking distance of shops, library, amenities and bus routes. The accommodation is arranged over two floors with shared space on the ground floor and bedrooms on both floors. The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 20 Shared space at the home comprises of a lounge and dining room. In the lounge and dining room there is sufficient seating for the individuals at the home to sit together as a group. There is a pay phone available in the corridor for people to make personal calls. Bedrooms are single and lockable, with a combination of the home’s furniture and individual’s personal belongings. The tour of the premises confirmed that the service provider takes steps to maintain the property to a good standard. Since the last inspection the downstairs toilet was converted into a disabled toiled and bathroom and there is new vinyl flooring in the toilets and bathrooms. Four individuals stated through the survey that the home is always clean and fresh. The Mendips DS0000026568.V365071.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): (34) & (35) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Individuals are supported by a competent, qualified and skilled staff team and to ensure they are suitable to work with vulnerable adults the recruitment process must be more robust. EVIDENCE: The personnel files of three staff working at the home were examined to test the robustness of the recruitment process. Completed application forms, written references and Criminal Records Bureau checks obtained are held within the files. To fully ensure that the staff employed at the home are suitable to work with vulnerable adults, full employment histories must be sought through the application form. Three staff are currently employed and the rota in place shows that one member of staff is rostered with the service provider. At night the service providers undertake sleep-in from their property, which has an adjoining door into the home. A relative said through the survey that the home usually gives the support to their relative at the home. It was stated, “ there are occasions The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 22 when a staff member is sick or away and understandably the quality of the service goes down temporarily.” This was discussed with the service provider and was aware of the comments from other occasions. Training records were examined and the staff employed have NVQ level 2. Since the last inspection, staff have attended Safeguarding Adults training, Mental Health Awareness and Mental Capacity Act Training. The member of staff on duty confirmed that the service provider arranges training for the staff at the home. The member of staff said that Safeguarding Adults, Parkinson Awareness and Manual Handling training was provided since the last inspection. It was also stated that refresher First Aid and Food Hygiene training was to be organised for the staff. One person giving feedback about the staff skills said that they know how to meet their needs. The relative that responded through the survey said that the staff usually have the right skills to meet the needs of their relative at the home. The Mendips DS0000026568.V365071.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. Individuals can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The service provider is also in day-to-day control of the home and has completed the Registered Mangers Award. The service provider is experienced and qualified to manage this care home. The service provider said that working “hands on” and through staff meeting consistency of care is maintained. It was further said that appraisals would The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 24 contribute to the consistency of care at the home. This system will follow a supervision format of eight weekly with each member of staff. The staff on duty was consulted about the leadership style used at the home. It was stated that there is an approachable style used at the home, the service provider listens to their suggestions and is open to discussions. Although three people refused to make comments about the home, one person made the following comments for the others. People at the home said they were grateful for what Mr Ghammy does for them, that he works hard and makes the environment homely. The four people that responded through the survey said that that the staff treat them well, listen and act upon what they say. The service provider must ensure that the care plan and recruitment processes are improved so that people receive consistent services from staff that are suitable to work with vulnerable adults. Individual’s mental health care needs must form part of the care plans and information must be specific to ensure a consistent approach to meeting needs. In terms of recruitment, application forms must require full employment histories. The fees charged at the home range from £355.00 - £593.64 per week. Facilities for the safekeeping of cash and valuables exist at the home and three people currently have money in safekeeping. The balances of cash were checked against the record and these were accurate and up to date. The completed fire risk assessments consider the potential of a fire in the home and where necessary take preventative measures to reduce the level of risk. The service provider ensures that the home complied with other legislation. Contractors are employed to service equipment annually, which includes gas safety and portable electrical equipment. The Mendips DS0000026568.V365071.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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 26 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 YA9 Regulation 13 (4) (b) Requirement Risk assessments that include a) reactive strategies for people with mental health care need must include the triggers, signs and symptoms of a deteriorating mental health. b) For people with aggressive and violent behaviours must include the triggers and safeguarding procedures that protect people from abuse must be included. c) For the person that abuses alcohol, the risk assessments must include an action plan to meet the goal identified. To fully provide a person centred approach to meeting needs, individuals like and dislikes must be incorporated into the care action plans. Care plans must be more detailed about the actions to be taken to meet the identified needs. Home’s application forms must seek full employment history from candidates wishing to work at the home. Timescale for action 30/10/08 2. YA6 12 (3) 30/10/08 3. OP6 15 (1) 30/10/08 4. YA34 7,9 & 19 Sch.2.6 30/09/08 The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 27 5. YA34 7,9 &19 Sch.2.3 References sought on behalf of candidates wishing to work at the home must be from the last employer. 30/09/08 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 The Mendips DS0000026568.V365071.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Mendips DS0000026568.V365071.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. 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