Inspection on 06/03/07 for The Thomas More Project

This inspection was carried out on 6th March 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Thomas More Project 06/02/06

The Thomas More Project 01/09/05

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 Bristol BS9 4HX Lead Inspector Sandra Jones Key Unannounced Inspection 6 & 7th March 2007 09:30 th The Thomas More Project DS0000026652.V332196.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 Thomas More Project DS0000026652.V332196.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 Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 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 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) Thomas More Project Mrs Janet Smith Care Home 11 Category(ies) of Learning disability (11), Physical disability (1) registration, with number of places The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate persons aged between 30 and 70 years. Date of last inspection 6th February 2006 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 is 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 DS0000026652.V332196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted unannounced in March 2007, which focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the residents, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from residents and staff. Eleven “Have your say” surveys were sent to residents in the home prior to the inspection and ten were returned. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. However, feedback from them was not received. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the pre-inspection questionnaire and notified incidences in the home. (Regulation 37’s). What the service does well: What has improved since the last inspection? Seven of the eight requirements made at the last inspection were actioned by the manager. The introduction of pictorial and symbolised Essential Life Plans ensures that the person can easily understand it. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 6 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 Thomas More Project DS0000026652.V332196.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 Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Admissions to the home are based on full assessments and ensure that the staff at the home can meet the needs of potential residents. EVIDENCE: The case record of the most recently admitted resident was examined and assessments were found in place. Needs assessments completed by Local Authority care managers were provided in advance of the admission to the home. The home conducted an initial assessment to ensure the needs of the individual could be met by the staff at the home. Eleven completed “Have your say” surveys were received from residents and indicated that they were given information about the home. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are helped to understand their care plans by the simple format and use of pictures Residents who have special communication needs may be disadvantaged. Residents may not be as fully involved in decisions about their lives as they could be given more encouragement EVIDENCE: Essential Life Plans (ELP’s) are being updated to include simple language and pictures. This will ensure that the people for whom it’s intended can understand the information. Information includes details about mobility and health care needs and some information about communication needs. Appearance and daily routines form part of the plan. It is acknowledged that documentation shows residents were present during review meetings. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 10 However, residents have not signed their ELP. The residents spoken with during the inspection said they attend review meetings and knew about their ELP. Where possible residents should be encouraged to sign to show that they are in agreement with the plan. This would show that they have been involved in decision-making about what happens to them. ELP’s are reviewed six monthly or whenever significant events occur. Three residents have particular communication needs, one person uses Makaton and two use gestures and vocal sounds. The manager reported that staff receive in-house Makaton training to ensure they are able to communicate with residents. For the two individuals that use gestures and vocal sounds information about the way they make decisions needs to be more specific to ensure staff understand their needs and wants about all aspects of their lives. The residents currently accommodated have families involved in their care. Restrictions are imposed on access to the kitchen and leisure times for one person evidenced through their ELP’s. Staff time limit an activity for one resident because this activity can become obsessive. The person’s plan does not give clear direction to staff about what to do if the resident refuses to stop the activity and becomes distressed. The action to be taken by staff needs to be made clear in the ELP so that all staff treat the resident in the same way. The front door has a keypad, which restricts access to the outside. The manager said that the purpose of the keypad was to prevent a previous resident from leaving the property without staff support. Although the resident concerned has left the keypad remains and residents do not have the code. This means that residents cannot come and go independently although staff and members of the Trust are able to. The manager needs to speak with residents about whether they want the keypad to remain or be shown how to use it to increase independence. Members of staff record residents’ daily activities, outcome of visits and observations of the person. There is a key worker system in operation and their responsibilities include supporting residents to make choices, 1:1 and organising ELP’s. Key workers are also expected to prepare monthly reports from the daily records, which are directly linked to ELP’s. Residents consulted were able to name their key worker and describe their role. Residents said that this is what staff do. Risk assessments are based on personal safety, medication and bathing. The risk and preventative measures are detailed within the risk assessments. The home maintains an accident book and staff are expected to formally report incidents. The nature of the event, a description of the incident or accident, outcome with preventative measures must be included within the report. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 11 Since the last inspection there were 33 incidents at the home. The manager said that persistent incidents are analysed and preventative measures are taken. She said that grab rails were installed for one person to prevent any further falls. However this was not recorded to show that incidents or accidents are thoroughly investigated. The manager must consider a more formal system of analysing incidents and accidents so that residents are protected wherever possible. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents may not be fully involved in deciding the activities they engage in. Their individual goals and aspirations may not be fully considered. The staff support residents to use the local community facilities and integrate into community life. Friends and family are welcome at the home. The house rules must be included in the Service User Guide to ensure potential residents are fully aware of the expectations before making decisions about living at the home. The residents say that the meals served at the home are good. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 13 EVIDENCE: The residents currently accommodated have structured daytime activities, with a life skills day at the home. Residents attend day care centres, college and employment. A care coordinator is employed at the home to undertake inhouse activities such as cookery courses, arts and crafts, photography and history of Bristol. The activity is then arranged in-house or externally. However although Essential Life Plans (ELP) include the activities people undertake they do not show that residents have chosen these activities for themselves. The home should make sure residents are consulted and their goals and aspirations are recorded in their ELP’s. This would ensure that residents are offered opportunities to plan and have the support and services they receive designed around what is important to them now and in the future. Staff support residents to attend clubs and to meet friends. Residents go to the local library, fitness centres, pubs, cinemas and shops. Generally members of staff accompany residents outside the home because the manger said that residents have not expressed a wish to leave the home unsupported. So that residents can be as independent as possible this practice should be reviewed for each person. The arrangements for visiting are described within the Statement of Purpose. It says that visitors are welcome at all times and visits can take place in private. Residents have family and friends that visit regularly. Residents consulted during the inspection said that staff welcome their visitors and for additional privacy, bedrooms can be used. The manager said that the Privacy and Dignity policy, Code of Conduct and choices about décor, leisure activities and key worker system sets the standards for respecting residents rights. All bedrooms are single and lockable with separate locking space for valuables. Where residents are not able to use keys their bedrooms are kept locked whenever the person is not at home to respect their privacy. The house rules were developed by the residents and relate to expected behaviours, noise levels, maintaining their bedroom tidy and household chores. House rules are appended onto the Licence Agreements and signed copies are held in care files. The house rules must be included in the Service User Guide to ensure potential residents are fully aware of the expectations before making decisions about living at the home. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 14 Residents stated that there is an expectation that they undertake household chores and keep their bedrooms tidy. It was explained that during their day at the home, they clean their bedrooms and staff assist depending on their level of independence. Regarding the staff observing their rights, residents reported that staff knock and wait for an invitation to enter their bedrooms and their mail is handed to them unopened. Residents reported that every Sunday during residents meetings each person has the opportunity to make meal suggestions for inclusion on the menu. They said that meals are good. Where alternatives are provided the meal served is recorded in the menu. The wide range of fresh foods, fruit and tinned goods supported the varied menus in place. A record of fridge, freezer temperature and cooked meats is maintained. The Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Members of staff ensure that residents’ personal care needs are met in a consistent and sensitive manner. Members of staff monitor resident’s health and where appropriate referrals for health care professionals are sought. For safe systems of medication to exist accurate recording of homely remedies must be maintained. EVIDENCE: Essential Life Plans (ELP) describes resident’s preferred daily routines which specify the individual’s morning and evening routines. The manager stated that three residents are fully supported with personal care and the staff prompt the other residents. One resident is a wheelchair user and hoists, ramps and assisted baths are in place to ensure this individual can maintain independence with personal care. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 16 Because of the aids and adaptation of the property, it is not necessary for the staff to use manual handling techniques. Residents consulted during the site visit described the personal care provided by the staff and confirmed that staff ensure their rights to dignity and privacy is maintained. Health care needs are also included within the individuals ELP. Information about NHS facilities is also detailed. Residents have regular dental and optician check-ups and annual visits to the chiropodist. Health care professional are involved and to ensure staff can monitor residents health care needs, additional information about signs and symptoms of deterioration is included Residents have annual health checks, one resident has regular district nurse input and female residents are invited for routine screening. One resident has diabetes, which is controlled by diet, and professionals monitor their health care. Another resident is showing signs of dementia. The manager confirmed that for this person the main focus of care has not changed since admission to the home. Although dementia care is not the persons primary need staff have had training to give them insight into the needs of people with dementia. Two staff have experience of working with people that have a diagnosis of dementia. Residents stated that staff will accompany them on GP’s visits and staff agreed that part of their role was to support residents on health care visits. Medications are administered by the staff through a monitored dosage system. The records of administration indicate that staff sign the records immediately after administration. Information leaflets are in place about the medications and the manager confirmed that medication profiles will be introduced and added to the individuals ELP. Homely remedies are administered from a stock supply when required and significant shortfalls were found in the balances of painkillers, cold and flu remedies. If staff do not record when medication has been given to residents there is a risk that medication could be administered again putting the resident at risk. A resident that self medicates described the systems in place to support medication administration. It was stated that lockable space was provided to ensure medications are safely stored, staff will discuss any changes in medication and monitor that the medication are taken correctly. The Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents’ views are sought, taken seriously and acted upon. Records of complaints must include the complainant’s level of satisfaction. Members of staff are able to recognise forms of abuse. The safeguarding policies and procedures must be clear to ensure staff take appropriate action. EVIDENCE: The home has a Complaints procedure whish details the steps to be taken. There is another procedure that is written in a simple format with pictures to ensure that residents can understand it. Residents are provided with the copies and during residents meetings and there are opportunities to raise concerns. Personal issues can be discussed with key workers during key workers during private meetings with staff. Since the last inspection eight complaints were received from residents about each other. The nature of the complaint, the actions taken and the outcomes are recorded. Residents said they were happy that they are listened to. However, there was no record to show whether the person making the complaint was satisfied with the outcome. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 18 Safeguarding Adults training was provided to raise staff awareness of all forms of abuse and the actions that must be taken. There is a home’s Adult Protection policy, which describes the aim of the policy along with the principles of abuse. However there was no clear information readily available to tell staff what to do if an allegation is made. The Whistleblowing policy specifies the aim of the policy and the actions to be taken by the staff. The policy does not specify that for allegations of abuse, staff will be suspended during investigations. Considerations must therefore be given to the appropriateness of staff working at the home while investigations are in progress. The policy must make it clear that staff might be suspended during an investigation for their own protection as well as the protection of residents. The Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the residents who live there. EVIDENCE: Thomas More home is a comfortable and homely environment. It is set in a residential area with local amenities nearby. The building is purpose built and arranged over two floors with bedrooms on both floors and shared space on the ground floor. The bedrooms are single, lockable. Bedrooms on both the ground and first floor of the property enhancing independence for those who use a wheelchair. Bedrooms viewed were found to contain a combination of the home’s furniture and resident’s personal belongings, which supported their lifestyle. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 20 Toilets and bathrooms are accessible and appropriately located to clients’ bedrooms. The ground floor bathroom has an assisted bath which enables residents with mobility needs to use the facility without support. The downstairs shower was recently refurbished. However, the upstairs showers are not decorated to the same standard. There is a large lounge with sofas and chairs that the clients use often. The home has also redecorated the smaller relaxation room into a computer room for both clients and staff usage. There is also a large dining area. Residents are encouraged to help with the cleaning of their bedrooms during their ‘Training Day’, but staff are responsible for the general cleaning. The home was found to be clean and hygienic on the day of the visit. Eleven residents stated through the “Have your Say” surveys that the home is always fresh and clean. One person stated that the home is usually clean. The laundry is sited away from the kitchen, which houses the washing machine, tumble dryer and sink. The floor is tiled and the walls are painted for easy cleaning. The Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The recruitment process must be more robust to ensure staff employed are suitable to work with vulnerable adults. Members of staff are clear about their role and residents state that staff treat them well. The programme of statutory training and vocational qualifications provided partially meets National Minimum Standards. Further training should be provided to ensure residents changing needs continue to be met. EVIDENCE: Staff personnel files contained completed application forms and two written references for each member of staff. Criminal Records Bureau (CRB) checks were obtained for all staff and for recent staff POVA First checks were also undertaken. In terms of the recruitment procedure, the application form does not seek full employment history from candidates. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 22 Additionally, the standard request for reference used by the home does not establish the validity of the referee. The procedure needs to be more robust so that residents are more fully protected. It was understood from the manager that in the last two years statutory training and NVQ has been the main focus of training for the staff. Members of staff have attended Safeguarding Adults, Safe Handling of Medications training. Future training programmes should focus on the specific needs of the residents to increase staff’s insight into the changing needs of the residents. Two members of staff were consulted about access to training and their role at the home. Members of staff were clear about the expectations of their role which is to support to their level of preference and the ethos of the home. Comments about training confirmed that statutory training and Vocational Qualifications were the main focus. Eleven “Have your Say” surveys were received from residents and indicated that the staff always treat them well. Ten people indicated that staff always listen and act on what they say and one person stated that staff are sometimes busy. Residents consulted were able to name their key worker and describe their role. The Thomas More Project DS0000026652.V332196.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is qualified and competent to manager the care home. As regular reports on the conduct of the home are not carried out by the nominated person (Responsible Individual) residents are not protected by checks on the service. Provision must be made for residents’ views to be formally incorporated into the future planning of the home. Residents live in a safe environment. The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Quality Audit is based on the premises, residents’ care and administration of information. The project manager undertook a full assessment of the premises and an action plan was devised to address what needed doing. There is an annual review of the policies and records and service user surveys are used to seek their feedback. The manager stated that surveys are analysed and where negative comments are made this is followed-up with the individual. There was written evidence to support this. While it is acknowledged that residents have input into the future plans for the home particularly with equipment records should reflect this. Health and Safety checks are conducted to maintain a safe environment for the residents. The home complies with associated legislation by the regular checks of gas and portable equipment. The records that relate to fire safety checks and practices were examined. Records indicate that these checks and practices take pace at the stipulated frequencies. The manager was consulted about the level of support that is provided by the Trust. It was understood that systems that support the manager in the role include supervision, managers meetings and weekly visits from the external manager. Legislation requires that a nominated person (Responsible Individual) visit the home unannounced monthly to check that the home is being conducted properly. Previous requirements for copies of the Responsible Individual’s reports to be sent to the commission have been made, as these visits were not being carried out. The requirement was made in September 05 and June 06 but has still not been met. Shortfalls in medication recording and administration should have been picked up as part of the regular checks. Although the residents are well cared for they may be at risk from this as referred to in this report. The manager and staff clearly care for the residents and provide a comfortable home for them to live in but they need to do more to encourage independence and enable them to make decisions about their lives and what happens in the home. The Thomas More Project DS0000026652.V332196.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 2 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 2 X X 3 X The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 26 no 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 YA7 Regulation 17(1) (a) Sch.3.l Requirement Details of any specialist communications needs of the service user and methods of communication that may be appropriate to the service users. Details of the means of making decisions by residents with communication must be included in their Essential Life Plans The registered provider shall supply a copy of the report required to be made under paragraph (4) (c) to- (a) the Commission: Monthly visit reports by responsible individual to be sent to CSCI. (Outstanding requirement, previous timescale 1/9/05, 06/02/06) A record of any limitations agreed with the service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. Timescale for action 30/06/07 2. YA39 26 (5) (a) 31/03/07 3. YA6 17(1) (a) Sch.3.(q) 30/06/07 The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 27 4. YA12 12(3) Action plans must be clear about the actions that must be taken for any breeches of restrictions and, where possible the person agreement sought The registered provider shall, for 30/06/07 the purpose of providing care to service users, and making proper provisions for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. Residents’ goals and aspirations must be included and form part of their Essential life plans. The registered person shall make 30/04/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Accurate recording of medications must be maintained to safeguard residents. The employer is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person, and has confirmed in writing to the registered person that he is so satisfied. The validity of references must be sought A full employment history, together with a satisfactory written explanation of any gaps of employment. Full employment histories must be sought through the application form. 5. YA20 13 (4) (b) 6. YA34 19 (4) (c) 30/04/07 7. YA34 7,9,19 Sch.2.6 30/04/07 The Thomas More Project DS0000026652.V332196.R01.S.doc Version 5.2 Page 28 8. YA39 24 (2) (b) Takes the views of service users and their representatives into account in deciding- (i) what services to offer to them, Residents views must be reflected into the future plans of the home 30/07/07 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 Thomas More Project DS0000026652.V332196.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. 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