Inspection on 01/09/05 for The Thomas More Project

This inspection was carried out on 1st September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Thomas More Project 06/03/07

The Thomas More Project 06/02/06

The Thomas More Project 29/03/05

The Thomas More Project 02/12/04

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 09/07/2008.

CARE HOME ADULTS 18-65 The Thomas More Project Thomas More House 33 Fallodon Way Henleaze BS9 4HX Lead Inspector Nicky Grayburn Unannounced 1 September 2005 09:30 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 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 Stationary 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 Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Thomas More Project Address Thomas More House 33 Fallodon Way Henleaze Bristol BS9 4HX 0117 9629899 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Thomas More Project Mrs Janet Smith PC (Care Home for personal care) 11 Category(ies) of PD Physical disability, for 1; LD Learning registration, with number disability, for 11 of places The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate persons aged between 30 and 70 years. Date of last inspection 29 March 2005 Announced Brief Description of the Service: Thomas More, 33 Fallodon Way, is registered with The Commission for Social Care Inspection as a care home for 11 clients aged 30 - 70 years with learning disabilities, including one client with physical disabilities. The house is purpose built, blends in well with its surroundings and situated in a quiet residential area. The house is a two storey building with single bedrooms on both floors and several communal areas for the clients to access. The garden is well sized and easily accessible from the house. It is close to local facilities and amenities and has its own transport to support clients in accessing community facilities. Clients are encouraged to participate in their local community and remain in contact with their relatives and friends. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting 6 hours to monitor good practice. Evidence of the standard of care was obtained through a tour of the property; informal interviews with the manager, staff, and two clients; reviews of records held and observation of interaction between the clients and staff team. The focus of the inspection was to pursue whether previous requirements and recommendations had been met and to ensure compliance with legislation is continuing. The manager requested that the service users are referred to as clients. There is currently one client vacancy at the home and three new members of staff. What the service does well: 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 Thomas More Project Version 1.40 Page 6 D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc 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 Standards Statutory Requirements Identified During the Inspection The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 7 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 standard(s) 1, 2, 4, 5 Clients have an opportunity to visit and assess the quality and suitability of the home. Clients and their supporters would benefit from the addition of the most recent report from the latest inspection to ensure they are better informed of the services provided. Client’s needs are assessed prior to moving into the home to ensure that it is a correct placement and that appropriate care can be offered. Clients are informed of changes regarding the terms and conditions of their residency at Thomas More. EVIDENCE: The manager confirmed, against the policy that clients have the opportunity to visit the home prior to moving in. Potential clients are offered a meal with all the clients, an especially planned activity with the home and an over night stay. Further to this the client can stay for two weekends prior to deciding. They are given the chance to meet all the clients, see their room, meet the senior staff and their potential key worker. They are also given a very userfriendly service user guide. The home is sent a needs assessment from Social Services and then the senior staff carry out an additional assessment. If the decision is that the client will move in, Thomas More obtain further information from the current carers regarding current medication, future appointments, transport details, and what furniture/personal effects they require. Once the client has moved in, a house meeting and welcome party is arranged for the new client and the established clients. There is a three month probationary period for all clients. There is one vacancy at present. The last client to arrive at Thomas More was in November 2002. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 8 The service user guide uses pictures and large format print as well as having photos of staff, however, is required to have the latest finalised inspection report with the correct details of the Commission for Social Care Inspection inside. Records within client’s files and policies must have the correct phone number for the Commission. Records of clients held user-friendly details of contracts, fees for Thomas More and terms and conditions from Knightstone Housing. Letters had been signed by the client and the manager in relation to the annual increase of fees. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 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 standard(s) 6, 7, 9, 10 Clients benefit from their changing needs being assessed regularly and having a key worker system. Clients are involved in their ‘Essential Lifestyle Plan’ to ensure individual choices are reflected and are supported to make decisions regarding their lives. Risk assessments enable clients to do as much as they can with minimal risk. EVIDENCE: All clients have a key worker. They spend one-to-one time with their client and also write the monthly reports. In some cases, these need to be kept upto-date. The files, which were assessed, had very clear Essential Lifestyle Plans, which were person-centred and were written in the first person. These are regularly reviewed and presented many details of the client’s life. Clients had evidently been involved in the process and made decisions about their lives for the future and the present. The files include areas such as ‘positive reputation’, ‘non-negotiables’, ‘preferences’, risk assessments, medication details, and financial capabilities. There were clear statements and agreements for the clients to understand areas of health and safety including why the kitchen and front door is locked at night, and any valuables the home is holding. This is good practice. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 10 Client’s meetings are held regularly, which was confirmed by a client, whereby they are consulted upon areas of the home and future events. The registered manager is the Appointee for some of the clients and understands the possibility of potential conflict of interests. Client’s financial records and purses are kept in the office in a locked cabinet alongside their files. A spot check of one client’s monies was carried out and was found to be correct on the day of inspection. There is also a ‘release of information’ record where the client has signed to state that they understand that other professionals may need to read their files. This is good practice. However, the list needs to include the Commission for Social Care of Inspection. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15 Clients benefit from many opportunities for personal development within the local and wider community supported through college and in-house training courses. The clients are supported with activities and retaining relationships outside the home. EVIDENCE: Clients enjoy a full programme of daytime and evening activities. Many go to day centres which are close by and engage in courses such as Art, Healthy Living, Dance, Cookery and more recently Popular Culture. The activities meet the stated needs as recorded in client’s care plans. Within the week, clients spend a day with the Day-Care Co-Ordinator who runs a Life Skills day, which includes cleaning, laundry, cooking, and going out to buy their toiletries. There is also a tailor made programme for interests the clients would like to pursue such as gardening, sewing, and photography. One client is producing a brochure detailing access for disabled people in the area. There are many arts and crafts sessions whereby the clients make items such as cards for their families and sell at their parties to fund further activities. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 12 During my visit some clients from Thomas More’s second home had come to visit and all clients and staff were outside playing skittles and dancing. Every second month the two homes have a friendly competition of skittles in the local skittle alley. One client who was spoken with is very much looking forward to this. The client also confirmed that they are always asked what they would like to do, in terms of activities. The home has an annual pass for Bristol Zoo and Slimbridge (bird sanctuary), which the clients very much enjoy. Clients often go to local pubs for lunch and go onto the Downs to fly their kites. Staff and clients produce a quarterly newsletter, which is sent to families, day centres, local church, neighbours to enhance their links with the local community. Clients also go on holiday once a year. This was confirmed by one client who the inspector spoke with who had been to Menorca this year with another client, and evidence was also seen in one client’s file of going to Portugal. One client has been volunteering at a local charity shop through his college course. A revised logistical approach will enable the client to continue with this. Four of the clients go to church regularly, one is in the choir and there is also a sub group of the church, called ‘Faith and Light’, who visit the home. One client has recently been baptised and showed the inspector the certificate displayed in his room. The manager said that he very much enjoyed the classes prior to being baptised. Within the client’s records there is a list of ‘Special People’ in their lives with addresses and birthdays. Next of Kin’s details are clear. The home organises regular parties for families and the community in order to keep all involved. There was also evidence that family members attend care reviews. Standard 17 was not fully assessed but the kitchen fridge was full of fresh vegetables and fruit. The displayed menu offered a range of healthy meals. In one client’s Essential Lifestyle Plan it stated that one preference was ‘party food’, and this was written on the menu for him for one meal in the week. One client said that the food was nice at the home. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 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 standard(s) 18, 19, 21 Clients receive personal support in the way they prefer and require through the Essential Lifestyle Planning system, which also ensures that client’s health needs are met. Resident’s wishes regarding death may not be met unless more detailed information is obtained. EVIDENCE: The Lifestyle Plans indicated how and when the clients want and like their personal care to be carried out such as shaving and cutting nails. There is an electrical bath hoist, which clients can use themselves in order to retain their dignity and independence. At the front of the client’s records there are details of client’s health care professionals. The manager described how one client does not have a dentist as he has no teeth and does not wish to have dentures. It is advised that the client retains dentistry visits regarding general oral hygiene. The dentist can advise further visits. One client arrived at the home with mobility difficulties so staff arranged with Frenchay hospital for callipers to be fitted. The client told the inspector that ‘they [callipers] are really good, I can walk around more now’. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 14 Standard 20 was not fully assessed on the day of the inspection. The Commission for Social Care Inspection has not received any notifications of medication errors. The majority of staff have been trained in medication administration with their pharmacist, who provides training throughout the year. Any new staff go to the pharmacy’s branch for the initial training. There is one member of staff per shift who is ‘on response’ who deals with all medication throughout that shift. On inspection, there were photos of all the clients and a signature list was at the front of the documentation. There is one client who self-medicates with staff support. The manager confirmed that the client has a lockable space for this. There are no controlled drugs used by clients nor stored on the premises. Some of client’s records displayed wishes after their death. This was discussed with the manager and needs to be completed for all clients by asking the individuals or the next of kin so that the client’s wishes are carried out with sensitivity and respect. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 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 standard(s) 22, 23 Clear polices and procedures, user-friendly forms, and staff training ensures that clients are protected from abuse. Regular client meetings and key worker sessions ensure that client’s views can be heard and acted upon. EVIDENCE: The manager, and a client confirmed that client’s meetings occur regularly with each client having an allocated slot for raising any issues. In the files examined, all had a very user-friendly complaints procedure, and the manager verified that all clients had a copy in their rooms and staff go through it with the clients intermittently. There are photos of people who the clients can approach to aid those with certain disabilities. One client spoken with said that they would talk to the manager or staff if they had any concerns or complaints. There is a clear and detailed policy regarding Complaints, Whistle Blowing and Adult Protection, which refers to the Abuse Protocol and No Secrets. There is also a reporting card to ensure procedures are carried out correctly. Freeways Trust provides Protection Of Vulnerable Adults (POVA) training for the home and the manager is currently organising another session to ensure that the new members of staff are fully aware of policies and procedures regarding protection. The permanent staff records looked at contained the relevant Criminal Records Bureau (CRB) checks and POVA first checks. The home is awaiting the return of the new staff member’s checks. The manager is to contact the inspector when these arrive. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 16 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 standard(s) 24, 25, 26, 28, 29, 30 Clients live in an attractive, safe and comfortable environment. Individual bedrooms reflect personal taste and promote independence. The shared spaces allow clients to socialise or choose to have quiet time. Clients enjoy a clean environment. EVIDENCE: Thomas More provides a homely atmosphere for the clients. The four bedrooms entered were decoratively personalised and displayed many photos, certificates, personal interests and possessions. The manager said that clients can choose which colour to decorate their rooms in. There is one vacancy at present and the room has been re-painted in a neutral colour as a ‘blank canvas’ so that the new client can decorate how they wish. One client who has mobility problems has a rail from the bedroom to the bathroom to aid mobility, especially at night. The one wheelchair user’s bedroom is on the ground floor as there is no lift to the upper floor. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 17 There is one large lounge and a large dining room for communal space. There is also a well-kept garden with a gazebo and quality sitting areas. The manager informed the inspector that the carpet in the lounge is being replaced in the very near future. The home has a new transport vehicle with a tail lift to enhance the independence of wheelchair users and those with low mobility. There is a relatively new shared area on one side of the property for a range of uses. There is a computer and the medication storage on one side and with a dividing set of shelves there is a sofa bed and television set on the other side. During the day clients can entertain family and friends away from the main areas, do any life skills training or relax. The sofa bed is used by sleep-in staff. The old staff sleep-in room is being transformed into a ‘quiet room’ for clients for relaxation. The home is generally clean and hygienic. There is an on-going problem with an unknown odour in an upstairs bathroom. This has been investigated by the maintenance team. No solution has yet been found. It is recommended that the home seek professional advice concerning the odour. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36 Clients are supported by a well-trained and competent staff team. Clients benefit from a confident and supervised team who have clear roles. Recruitment practice needs to adhere to the policy and legislation. EVIDENCE: Records of four members of staff were inspected and three staff members were informally interviewed. A client spoken with praised the staff team and understood the role of her key worker. The client uses the call bell and confirmed that staff attend quickly. There are three new members of staff at the home. One has not been given a start date as yet and has only just had the interview. The inspector met one very enthusiastic new staff member who was meeting the residents and staff team. The records and induction for the newest members were looked at. The induction programme meets current National Minimum Standards. However, there was no record of a ‘Criminal Records Bureau’ check or ‘Protection Of Vulnerable Adults First’ check for the new staff members. It is the Project Manager who deals with this area and this person was not at the home on the day of the inspection. The manager was confident that the Project Manager would have carried these out. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 19 The inspector asked the manager to contact the inspector to confirm whether the POVA First checks had been received as soon as possible. It was explained that staff cannot work in the home until they have at least a POVA check, and then only under supervision until their CRB is returned. In addition, it was discussed with the manager, and it is recommended that the reference request forms have a space for the referee’s signature, print and date in order to verify the reference. Further, letters of offer of employment should state that it is on condition of satisfactory police checks and references. All staff have a three month probationary period. The manager understood that staff were unable to undertake any responsibilities or carry out any roles unsupervised until the relevant police checks had been received. The manager is hoping to complete her National Vocational Qualification (NVQ) level 4 and Registered Managers Award by November 2005. Three members of staff are due to finish their NVQ Level two by December, and two members have completed their Level 3. All staff records looked at had the relevant and statutory training in place. The manager also keeps a training matrix to ensure that all knowledge and competencies are up-to-date. Staff spoken with feel well supported by management, and other staff. The manager carries out regular supervision with all staff and records of this were seen in the staff files. The manager is supervised on a monthly basis by the Project Manager. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41, 42 The registered manager demonstrates good leadership and management skills. Clients are assured that they are safeguarded by the home’s policies and procedures and well-organised record keeping. Clients, and their relatives, are consulted upon the development and review of the home. The health, safety and welfare of clients is promoted. EVIDENCE: It was evident that the manager, deputy manager and staff on shift were confident and ensured that events ran smoothly. The Home Manager carries out quality assurance measures to ensure that client’s views are sought and underpin the development of the home. There were user feedback forms to view, which had been completed recently by relatives and visitors. The majority stated that they were ‘very satisfied’ and that the home is ‘very good’. The home also carries out care plan audits. It is required that the monthly visits (regulation 26) reports are sent to the inspector. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 21 The policies and procedures files were looked at and reflected the work carried out with in the home. The manager and staff spoken with were aware of procedures such as fire, complaints and protection. The office records are very well organised. The records for clients complied with Schedule 3. Confidential records, as well as client’s financial matters are kept in a metal lockable cabinet in the office. Keys are only held by the manager and deputy manager. If staff wish to access client’s files, they can do so by simply asking. Health and Safety checks were inspected and are carried out duly. Gas and electrical appliance checks are undertaken every Thursday by a designated staff member. The fire log containing tests for emergency lighting, fire fighting equipment, fire alarms, staff fire training records, and the risk assessment were looked at and are all carried out within the appropriate timescales. There had been a fire drill the day before, which stated that there was a ‘very good response from staff and residents co-operated well’ with an evacuation time of 1minute 10seconds. A client confirmed that this had occurred and understood the importance of the drills. There is a small problem with one of the doors not clicking shut. A contractor was at the home at the beginning of the inspection assessing the problem and would be retuning the following day to resolve it. The Avon Fire Brigade visited 27/10/04. As stated earlier, staff have the required statutory training to ensure the health and safety of clients, such as manual handling, first aid, food hygiene and infection control, is safeguarded. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Thomas More Project Score 3 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 3 3 3 x D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 23 O 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. 2. 3. 4. Standard 1 21 23 39 Regulation 5 (d) 12(3) 19 Sch 2, para 7 26 Requirement The Service User Guide must have the most recent finalised inspection report from the CSCI. Manager to obtain information regarding clients wishes at time of death. To confirm with the inspector that new staff members have POVA and CRB checks. Monthly visit reports by responsible individual to be sent to CSCI. Timescale for action 14/09/05 05/12/05 09/09/05 01/09/05 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. 4. Refer to Standard 10 30 34 34 Good Practice Recommendations Include CSCI on Release of Information form for clients confidentiality. Seek professional advice for odour as discussed. Inlcude space for referees signature, print and date on reference forms. Inform potential new staff that employment is on condition of satisfactory references and CRB check. The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury Bristol 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 The Thomas More Project D56_D05_S26652_ThomasMoreProject_V246647_010905_Stage4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!