Inspection on 20/02/07 for The Thomas More Project - 97 Cromwell Road

This inspection was carried out on 20th February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Thomas More Project - 97... 06/12/05

The Thomas More Project - 97... 19/08/05

The Thomas More Project - 97... 31/01/05

The Thomas More Project - 97... 13/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Thomas More Project - 97 Cromwell Road St Andrews Bristol BS6 5EX Lead Inspector Sandra E. Jones Key Unannounced Inspection 20th & 21st February 2007 09:30 The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.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 - 97 Cromwell Road DS0000026533.V329349.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 - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Thomas More Project - 97 Cromwell Road Address St Andrews Bristol BS6 5EX 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) 0117 9423739 0117 9423739 Thomas More Project Miss Andrea Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 18 - 64 years who have a learning difficulty 6th December 2005 Date of last inspection Brief Description of the Service: Cromwell Road is operated by the Thomas More Project, a charitable organisation, which provides support for people with learning difficulties. The present age range is between 25 yrs to 64 yrs - the home, however, have recently submitted an application to reduce the age range so they can accommodate a new resident who is 20 yrs old. The house itself is residential in style and blends in well with the local community. It is close to many local facilities and amenities. The home has its own transport. The fees range from £414.38 - £553.89 per week. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key visit was conducted unannounced in February 2007 and 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 procedure. During the site visit, the records were examined, a tour of the premises conducted and feedback sought from residents and staff. Six “Have your say” surveys were sent to residents in the home prior to the inspection and six were returned. Feedback from relatives and Health and Social Care Professionals was sought through comment cards. Information from these sources has been collated and where possible detailed throughout the report. 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? Repairs and redecorations continue to be made to the premises ensuring that residents have a homely environment. The home continues to maintain and develop the high standards of care. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.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 - 97 Cromwell Road DS0000026533.V329349.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 - 97 Cromwell Road DS0000026533.V329349.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. EVIDENCE: The Admission policy and procedure describes the steps to be followed for prospective residents. It describes the aim of the policy and the management of referrals. The arrangements for introductory visits and probationary periods are clearly detailed within the policy. The case records of the most recently admitted person was examined and completed initial and medical assessments were found in place. The assessments in place establish that staff have the necessary skills and resources are available to meet needs of the person. The most recently admitted resident described their experience of the admission process. It was understood that visits to the home took place before admission and Service User Guides were provided to enable decisions to be made about the home. Residents feedback on the standards of care was sought through surveys and during the site visit. Four residents indicated through the surveys that they were asked if they wanted to move into the home and had received enough information before their admission. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 9 At the previous inspection, a signed contract was not in place for the most recently admitted resident. A recommendation was made at the previous inspection, for the manager to ensure all contracts are up to date. As this recommendation remains outstanding and residents have not been notified of fee increase, a requirement will be made through this inspection. The manager must ensure residents have a contract and are informed of any changes to the contract. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents confirmed that they are involved in the care planning process. A person centred approach to meeting needs must be considered for the identification of preferences, needs and wants. Members of staff support resident to make decisions over aspects of their lives. Accessibility of information must be augmented so that residents can be further empowered to make decisions. Risk assessments are completed for activities that may involve an element of risk. Support plans must be more detailed for residents that are left home alone and for locking the kitchen at night. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each person accommodated has a support plan which is sectioned into the support required, the person responsible for meeting the need and the action plan. The residents’ signature is included in each support plan and generally focuses on safety, personal care, relationships and independent living skills. The deputy manager was present during part of the inspection and explained that the purpose of the support plans is to guide the staff to meet specific areas of the individuals identified needs. While it is clear that support plans are developed for each area of need, a person centred approach to meeting needs must be considered. With a person centred approach to meeting needs, key principles of rights, choice, inclusion and independence will be integrated into the way residents needs are met. It is then the responsibility of the staff to focus on developing action plans with individuals to support the identification of their preferences, needs and wants. There is a keyworker system in operation and there is an expectation as part of the role to undertake reviews and complete monthly monitoring reports. Keyworkers giving feedback described their role and the residents supported the descriptions of the role. It was further stated by a keyworker that the role was about empowering residents to fulfil their aspirations. The six monthly reports and monthly monitoring reports were examined and are not linked to the support plans. The actions to be taken as a result of the review are not clear. Annual reviews are clearer and more formal. The outcome of the meeting is recorded and amendments to the support plans are described. Three residents were consulted about their input into the care planning process. Residents confirmed their awareness of their support plans and reinforced the findings that they attended annual reviews and had access to the plans in place. It is evident that one person at times exhibits aggressive and inappropriate behaviour. The support plan in place ensures that the staff use a consistent approach to managing the situation. Triggers, signs and behaviours presented along with the actions to diffuse potential aggressive behaviours are clearly described in the support plans. Another resident has mental health care needs and possibly dementia. It is acknowledged that the support plan in place addressed some of the behaviours exhibited, the plans must be more detailed about meeting this individuals support needs. Individual daily activity checklists are used to record times that residents rise, retire and activities. Outcomes of visits are recorded separately; health care reports are completed and kept in residents’ case records. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 12 The manager stated that residents are able to make decisions, one resident uses some “Makaton” to communicate and one person can read and write. At present staff explain the choice to residents in a simple way. For residents to make decisions without staff having to explain the choices, the manger must consider accessibility by developing existing picture formats. The manager stated that accessibility is already being considered and, residents are in the process of deciding on their holiday destination. Pictures and greater information is being used to inform the choices. The kitchen is locked at night because one person is at risk. The risk assessment must be clear about the reasons for locking the kitchen. Where activities involve an element of risk, support plans are formulated. Support plans for accessing community facilities without support, home alone and independent living skills are in place. Support plans are clear about the length of time that residents can be left at home without supervision. A picture phone is available to residents to contact staff in the event of an emergency when they are home alone. The support plan must be updated for one person to include agreed preventative measures before staff leave the home. The home maintains an accident book and since the 3/04/06. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents lead interesting and active lives. Once a person centred approach to meeting residents needs is introduced, residents will have opportunities to express their wishes and goals. Residents are members of the community. Members of staff support residents to strength links with family and friends. Residents are valued as individuals and are giving opportunities to develop their independence. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 14 EVIDENCE: Residents’ feedback was sought about the standard of care through surveys and consultation during the inspection visit. Six “Have your say” surveys were received from residents and indicate that they can do what they want each day. Residents consulted described the community-based activities undertaken during the day. The rota of activities confirms that residents attend college courses, day care centres and are voluntarily employed. Residents aspirations and goals are not part of the care planning process. As part of the person centred approach to meeting needs, residents aspirations and goals with education and occupation must be sought. Risk assessments form part of the support plans and are in place for residents that access the community without staff support. The manager states that residents access local shops, cafes, cinemas and restaurants. Residents also go bowling and visits to the theatre are arranged twice yearly. Evening activities are arranged in advance and where appropriate additional staff are rostered. It was also understood that that there is home’s vehicle, which is used for outings and residents contribute to the running cost through their fees. The visiting arrangements are that visitors are welcome at all times. Two completed comment cards were received from relatives and positive comments were received about the welcome received from staff and it was confirmed that visits can take place in private and they are kept informed about important matters. Residents consulted during the inspection agreed with the comments made by relatives. The Confidentiality policy, Code of Practice and Statement of Purpose set the approach that is used to respect residents individuality. Bedrooms are single and lockable which supports residents rights to privacy and dignity. Residents giving feedback stated that staff knock and wait for an invitation to enter bedrooms and their mail is handed to them unopened. During the site visit residents made comments about the rules and routines of the home. It was understood that the rules are about smoking, drinking and entering other residents bedrooms. It was explained that smoking is only permitted outside and residents are expected to respect each other’s privacy. There is also an expectation that residents maintain their bedrooms tidy and undertake some household chores. The manager stated that residents have allocated chores around meals and meal times. For example, laying-up, cleaning tables, drying-up, wiping surfaces and sweeping the floor. Residents also have a training day at the home where they undertake their personal laundry and tidy their bedrooms. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 15 Residents stated that they have input into menu planning and the menu in place included the name of the resident that suggested the meal. The wide range of fresh vegetables, tined and dried provision supported the menus in place. A record of the food served to the residents at lunch and teatime is not currently maintained. The manager must ensure that a record of meals served to residents is maintained. The home maintains a record of fridge and freezer temperatures. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 16 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. The residents are satisfied with the personal support provided by the staff. The health care needs of residents are monitored and appropriate action and intervention is taken. Medication systems are safe. The systems are to be further developed to maintain safe systems of medication. EVIDENCE: Residents personal care needs is described in their support plans. Members of staff record the times that residents rise and retire each day and it is evident that at weekends there is a more relaxed atmosphere. The residents are fully ambulant and the property does not allow for technical aids to be installed because of the age and size of the property. Handrails are installed on the stairs to prevent falls. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 17 Documentation is place indicated that residents health care is monitored by the staff and where appropriate referrals for specialist input is sought. Residents have access to Community Learning Disabilities Team (CLDT). The staff record outcomes of health care visits and listed are the reasons for the visit, and the outcomes of the appointment. Comment cards were sent to Health and Social Care Professional that have contact with the care home. A completed comment card was received from the psychologist and positive comments were made about the communication systems, staff demonstrating a clear understanding of residents needs and specialist advice is acted upon. Additional comments were made regarding staff’s input at review meetings and the homes environment having a pleasant and supportive ethos. Residents are registered with a GP and access local community facilities, regular visits are arranged to the dentist, optician and chiropodist. The manager stated that residents on Continuing Health Care status are invited for screening. Residents stated that staff will accompany them on visits to their GP’s and hospital appointments. Since the last inspection a monitored dosage system was introduced. The records of administration were checked and found to cross-reference with the medication held within the system. It is clear from the records of administration that there is appropriate use of code by the staff. The manager has confirmed that medication profiles will be introduced and further consultation will be taking place with the supplier of the monitored dosage system. The staff administers homely remedies from a stock supply when required by residents. Remedies for hay fever, painkillers and sore throats are administered at the home. A separate record of homely remedies is maintained which includes the name of the person, the time of the dose and balances of medication held. The medications held were consistent with the recorded balances. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 18 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 and their feedback is taken seriously and acted upon. Residents state that they are very satisfied with the service provision, feel very safe and well supported by an organisation that has their protection and safety as a priority. EVIDENCE: The six “Have your say” responses received from residents indicated that they know who to speak to if they are not happy and they know how to make a complaint. During the inspection, the residents consulted endorsed the responses from the surveys. It was further stated that members of staff take their concerns seriously and will act upon them. The Complaints procedure format for residents uses simple language and symbols to ensure their understanding. Signed copies of the complaints procedure is kept in residents files to evidence residents awareness. Accessibility of the procedure was discussed with the manager during the inspection and it was understood that copies would be handed to residents. It was explained that residents were given copies of the procedure sometime ago and updated copies will be provided. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 19 There were no complaints received at the home or the CSCI since the last inspection. “Have your say” surveys from residents indicated that staff always treat them well. Members of staff consulted are able to recognise all forms of abuse and are aware of their responsibilities towards reporting abuse. The manager has indicated through the pre-inspection questionnaire that the Equal Opportunities, Adult protection and Whistleblowing, which endorse a commitment to safeguarding adults from abuse, are in place. Through discussion with the manager it was reported that since the last inspection, staff issues are being managed through personal development. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 20 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 is well maintained and homely and residents say the environment is kept fresh and clean. The wet room in the basement must be redecorated and, a full risk assessment must be conducted for all laundry facilities. EVIDENCE: Cromwell Road is a small residential style house that blends well with the community. It is arranged over four floors with shared space on the ground and lower floor and, bedrooms on all floors. The property is within walking distance of shops and bus routes. Alterations continue to be made to make it homely and comfortable for the residents living at the home. Action regarding minor repairs and redecoration was taken to meet previous requirements and recommendations. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 21 During the tour of the premises the manager explained the redecoration that was to take place. While the bathrooms and shower room were recently decorated, the wet room in the lower ground floor is in need of redecoration. It was understood that the two attic en-suite rooms were to be redecorated in the near future. The six residents indicated through “Have you say” surveys that the home is always fresh and clean. The washing machine is currently sited in the kitchen, Infection Control Guidance for care homes recognise that it is not always practicable for separate laundry facilities. The manager must therefore undertake a full risk assessment on all laundry facilities to ensure that crossinfection is kept to a minimum. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 22 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 staff are clear about their role and what is expected of them. Residents report that staff working with them know what they are meant to do, and that they are able to meet their needs. The manager recognises the importance of training, and provides a programme that meets any statutory requirements and the National Minimum Standards. Additional training will be provided to ensure residents changing needs continue to be met by the staff EVIDENCE: The personnel records of the staff were examined during the inspection. Completed applications forms, two written references and Criminal Records Bureau (CRB) checks conducted were found in place. For the two most recently employed staff POVA first checks were undertaken. Supervision records are kept within personnel files and the three most recently employed staff have undertaken the induction programme. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 23 Members of staff were consulted about access to training. It was stated that training and refresher training is regularly provided. It was further stated that staff have access to vocational qualifications. Since the last inspection staff have undertaken Safeguarding Adults, fire, COSHH and First Aid training. The manager was consulted about training that is specific to the needs of the residents accommodated. It was understood that the staff attended epilepsy, dementia and Downs syndrome courses. The manager explained that dementia training may be provided again because one resident may have a diagnosis of dementia. Additionally, the current staff team have not attended autism training and this training will also be provided. The manager further described the arrangements for staff to access training. There are opportunities during appraisals to set personal development goals and during supervision for staff to identify training needs. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 24 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 to manage the care home and ensures that the staff team have insight into the needs of the residents. Steps must be taken to improve the Quality Assurance system to ensure residents views are reflected in the future plans of the home. Residents live in a safe environment. EVIDENCE: The manager explained the support provided from the external manager and the training that will be undertaken. In terms of support, it was understood that the external manager visits weekly and can be contacted at any time. The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 25 Trustees are also available and there is a good house committee. The manager further stated that the home’s allocated hours allow for sufficient supernumerary time to undertake the responsibilities of the role. Residents and staff giving feedback about the conduct of the home made positive comments about the managers’ style of management. A member of staff stated that the manager was “hands-on”, confirmed that supervision occurred regularly and problems are resolved straight away. The manager stated that audits were introduced to seek residents’ views on catering, personal care, daily living, premises and relationships. The Quality Assurance system must be further developed to encompass the feedback sought from a variety of sources. An annual development plan must then be set which is then incorporated into the cycle of planning, action and review. 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 Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 26 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 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 3 x The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 5 (1) (b) Requirement Each resident must have a copy of the terms and conditions of accommodation including the amount and method of payment of fees. Review home alone policy. (Previously required 10/12/05). A person centred approach must be used to seek residents preferences needs and wants about meeting their needs. The basement shower room must be decorated. A full risk assessment of the laundry facilities must be conducted. The manager must augment the existing Quality Assurance system Accessibility of information must be augmented for the residents at the home. Timescale for action 30/04/07 2. 3. YA9 YA6 13(4)(c) 12 (3) 30/04/07 30/06/07 4. 5. 6. 7. YA24 YA30 YA39 YA7 23 (2) (d) 13 (4) (c) 24 17 (1) (a) Sch. 3. (l) 30/09/07 30/04/07 30/09/07 30/05/07 The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Thomas More Project - 97 Cromwell Road DS0000026533.V329349.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 DS0000026533.V329349.R01.S.doc Version 5.2 Page 30 The Thomas More Project - 97 Cromwell Road © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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