Inspection on 18/01/07 for The Turrets

This inspection was carried out on 18th January 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Turrets 13/03/06

The Turrets 08/09/05

The Turrets 21/03/05

The Turrets 11/10/04

The Turrets 12/03/04

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 Turrets 7 - 9 Glebe Road St George Bristol BS5 8JJ Lead Inspector David Smith Key Unannounced Inspection 18th January 2007 09:30 The Turrets DS0000026618.V328066.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 Turrets DS0000026618.V328066.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 Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Turrets Address 7 - 9 Glebe Road St George Bristol BS5 8JJ 0117 9554058 F/P0117 9554058 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) Mrs Lorna A Arnold Mrs Lorna A Arnold Care Home 10 Category(ies) of Learning disability (10) registration, with number of places The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 10 persons aged 18 - 64 years with learning disabilities 13th March 2006 Date of last inspection Brief Description of the Service: The Turrets is a home for males and females with mild learning disabilities, aged between 18 and 64. Mrs Arnold is the registered provider and manager who is actively assisted by her eldest daughter. The philosophy is that of an extended family offering support and guidance within a secure framework and structured home life. Local shopping and other public amenities are within walking distance. The home is near a bus route accessing Bristol, Hanham, and Kingswood. Respite and Nursing accommodation are not provided. The current fees for this service range from £343.35 to £610.97 per week, depending on the support needs for each individual. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a Key Inspection of this service. I gathered information during this visit through discussions with individuals who live in the home, the Registered Manager, Deputy Manager and care staff. Interaction and communication between staff and individuals was also observed during the course of my visit. Care plans and associated records were examined together with Risk Assessments, accident/incident reports, medication, finances, staffing and health and safety records. I was also provided with a tour of the communal areas of the home and viewed some of the individual’s bedrooms. The Commission also provided the home with individual’s Survey Forms and a range of Comment Cards for stakeholders prior to this visit. Two people who live in the home completed and returned a Survey and five Comment Cards were also returned. The people who live in the home wish to be described as “people” or “individuals” rather than residents or service users. This has been acknowledged and reflected in this report. What the service does well: Each individual who responded by survey said they liked living in the home and chose what they would like to do. One said, “I am very happy where I am” and another “The Turrets is a good place”. Each person who lives in the home told me they were very happy living at the Turrets and that they felt well cared for. The service remains focused on the people who live in the home. The long-standing staff team demonstrate an extremely good knowledge of each individual’s care and support needs. The service provides a comfortable and structured home life for each person who lives at The Turrets. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Turrets DS0000026618.V328066.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 Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each individual is provided with relevant information about the home, to enable them to make a choice about where to live. EVIDENCE: The Statement of Purpose and Service User Guide remain as previously submitted to the Commission. These provide each person with sufficient information regarding the home to enable them to make an informed choice of whether they wish to live at the Turrets. Each individual spoken with, and those who responded by survey, said that they were asked if the wanted to move into the Turrets and were provided with enough information to enable them to decide if the home was the right place for them to live in. There have been no new admissions to the home for a number of years. The Turrets DS0000026618.V328066.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): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide clear information to enable staff to support each person who lives in the home. Each care plan is reviewed regularly. The home should continue to review the accessibility of information for each individual. Staff have a good knowledge of the support needs and communication abilities of each person as relationships between those living at the home and the staff team staff are very well established. The risk assessment process supports each person to take risks as part of their lifestyle. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 10 EVIDENCE: A care plan template is in use, which covers the following areas. Residential Care, Personal Care, Living Skills, Risks, Mobility, Reading and Writing, Shopping and Money, Personal Safety, Emotional Needs, Social Needs, Employment, Health and Privacy. I examined four care plans during my visit. These all provided good levels of information relating to the support needs of each individual. Each person continues to have the opportunity to enter his or her comments throughout their care plan. Each care plan had been recently reviewed. The date and attendees of the last review meeting are added to the care plan but no formal record or minutes of the review meetings are currently maintained. However, comments are added or amendments are made to each plan, often by the individual concerned. Each relative, who responded by comment card, said they are always kept informed of important matters affecting their relative and are consulted about their care. Care plans and daily records for each individual are not currently in a format which is accessible to them. However, the home has begun to adapt some information by using photographs and is considering transferring care plan information into ‘Essential Lifestyle Plans’ for individuals who would benefit from this. The accessibility of information remains a key element in the provision of person centred services and therefore the progress in this area will be focused upon during the next inspection. Each individual spoken with and those who responded by survey said they made decisions about what to do each day and that they were able to do what they wanted. Staff spoken with and observed during my visit demonstrated a very good knowledge of the support needs and communication methods of each person who lives in the home. Each person is encouraged by staff to make informed choices. Each individual spoken with said they were involved in reviewing their care plans and attended these meetings. They can also speak to ‘Lorna or Lucy’ (Mrs.Arnold or her Daughter) if they wanted anything changed or were unhappy about any issue. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 11 The Risk Assessment process supports individuals to take risks as part of an independent lifestyle and to promote their welfare and safety. These form part of each individual’s care plan and are reviewed regularly. The Turrets DS0000026618.V328066.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): 11, 12, 13, 14, 15 and 16. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person who lives in the home has opportunities to take part in a range of community and leisure activities. Individuals are supported to maintain friendships, relationships and links with their family. Each individual’s rights are recognised and promoted in their daily lives. EVIDENCE: Each person who lives in the home is supported by staff to engage in a variety of work and leisure activities. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 13 Some people who live in the home are currently in paid employment. Other individuals attend a variety of drop-in centres, day services, Disabled Christian Fellowship services, college or educational courses. The manager remains instrumental in accessing relevant courses for individuals, especially when day services have declined or closed. One person told me that they currently work five days per week at a local Day Centre. They “really like” this job, which Lorna and helped them find. Another individual told me they work at a laundry, two days per week. They really like going to work and “have made many friends there who help me”. Many people who live in the home are able to access the community independently. People enjoy going shopping, the cinema, swimming, bowling, to the pub and out for meals amongst other activities. The household are involved with planning holidays or day trips. Records examined described trips to Weston, the Cotswolds and a holiday to Crete. These may be supported by staff members, but some individuals chose to go on trips or holidays with family or friends. Many people have well-established links with their families and see them often, sometimes staying overnight. Family members are also invited to attend review meetings, if the individual wishes. Several people have friendships outside of the home and can entertain visitors if they wish. Each relative who responded by comment card said they were always welcomed to the home at any time, can visit their relative in private and were satisfied with the care provided by the home. One said their relative “considers the Turrets as a home from home. We endorse these sentiments” and another said their relative was “very happy and well looked after”. It was evident that the home respects each individual’s privacy; whilst touring the home, staff knocked on doors prior to entering individual’s rooms. Observation during my visit and discussion with staff evidenced that each person who lives in the home is treated with respect and dignity. Each person is seen as an individual and treated as such. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are supported in their preferred manner and their physical, emotional and healthcare needs are well met. Experienced staff have a good knowledge of each person who lives in the home and how to provide appropriate levels of support. Individuals are protected by the home’s policies and procedures in relation to medication administration. EVIDENCE: Each person who lives in the home is registered with a local GP, Dentist and other relevant professionals such as an optician. The home does ensure each person accesses other relevant health care professionals where necessary such as the Community Nurse. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 15 The care plans in place for individuals provided clear guidance for staff on how they should support those living at the home with their personal care. Individuals had recorded their preferences and the assistance required with personal hygiene and personal support. In general each person is independent with their personal care although varying degrees of prompting or help is required by some. Each individual is able to speak with doctors, dentists and other health care professionals and give their consent for treatment. Staff normally accompany individuals to attend appointments. One individual spoken with told me they had just returned from a stay in hospital. Whilst they were hospitalised staff from the Turrets visited regularly. They said they were “very happy to be home”. It was evident at this inspection that the management and staff spoken with are sensitive to the healthcare and emotional needs of those living at the home and through observation and discussion demonstrated respect to the wishes of each individual. The staff team have a good knowledge of each person’s support needs and they ensure that appropriate support is offered/provided. The comment card completed by the home’s GP said ‘the home works in partnership’ with them and that any specialist advice they give is incorporated in care plans. They are able to see their patients in private and feel that staff demonstrate a clear understanding of each individual’s health care needs. They added that the Turrets “provides a very high standard of care to its residents”. The home uses a monitored dosage system of medication administration, which is provided by a local pharmacy. All medication is stored securely in the home’s office. This is usually dispensed by Mrs. Arnold, but her daughter will dispense medication in her absence. Clear records are maintained of all medication dispensed to people who live in the home and I found all of these records to be up to date. The home has a policy on medicine administration, which was last updated in January 2006. The home’s GP confirmed on their comment card that they feel each person’s medication is appropriately managed by the home. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to communicate their views and they can be confident that they will be listened to and their views acted on if necessary. There are satisfactory arrangements in place to manage complaints or any allegations of abuse. Reactive strategies are in place to support individuals who display challenging behaviour. These are now regularly reviewed and updated. EVIDENCE: The home’s complaint procedure, including the CSCI contact details, is available and is given to each individual who signs to acknowledge receipt and understanding of this procedure. There have been no complaints recorded since the last inspection. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 17 Each individual who responded by survey said they knew who to speak to if they were unhappy, how to make a complaint and that staff ‘always listened to them and acted on what they said’. The individuals I spoke with all confirmed to me that they could express their views. They each said if they were unhappy about any issue they would talk to ‘Lorna or Lucy’. Each person said they would be happy to do this and felt sure that they would be helped to solve the problem. Each relative and the GP who responded by comment card said they are aware of the home’s complaints procedure and they have never had cause to make a complaint. The current group of individuals living in the home display little physical or verbal aggression. Physical intervention is not required. The home therefore has limited reactive strategies in place for individuals who display behaviour which can be interpreted as challenging. These are now regularly reviewed and updated. The home keeps records of accidents and incidents and would also notify the CSCI of any significant event which occurs in the home. I did discuss the scope of the notifications with the Mrs.Arnold as one incident where one individual’s actions brought him into contact with the Police Authorities had not been notified to the Commission. I also provided a copy of the Commission’s written guidance regarding the type of events which should be notified. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Turrets provides a homely, comfortable and safe environment for each person who lives in the home. Each person is supported to individualise his or her bedroom. The home was clean, tidy and hygienic on the day of my visit. EVIDENCE: The Turrets is a large Victorian property, which blends well with the local community. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 19 The home comprises of two large linked properties. This provides one spacious home for the individuals to live in. There is a communal lounge and a separate activities room which can be used for table games and playing music. There is a large laundry and also a patio area at the rear of the home. All of the communal areas are well furnished and tastefully decorated. The home is well maintained and any minor repairs or refurbishments are attended to quickly. On the day of my visit contactors were repairing a handle to one window in an individual’s bedroom, while another was completing the replacement of the flooring in the home’s laundry. Each person’s bedroom is decorated to reflect individual likes/tastes. Each person has photographs, pictures, books and other items, which help to personalise their rooms. Three individuals did invite me to view their rooms and told me they liked them, could have any personal items they wanted and helped to keep their rooms clean and tidy. The kitchen is appropriate for the nature of the home. All individuals are encouraged to use the dining room for meals and snacks. The standard of cleaning in the house was very good throughout on the day of my visit. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The relationships between staff and those living at the Turrets are well established. This provides a supportive environment for each individual who lives in the home. The home has sound recruitment policies and procedures. These help to ensure the welfare and safety of each person who lives in the home. All staff must be provided with all mandatory training and any additional appropriate training to enable them to support individuals and promote their welfare and safety. Staff appraisals have been introduced, however these remain inconsistent. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 21 EVIDENCE: There is a small, longstanding group of staff that have worked at the Turrets since it first opened in 1995. Two members of the family are regularly working in the home. Two other family members work in the home when it is possible for them to do so. All staff carry out various roles in care and support work, catering and general housekeeping duties. Discussions with staff members and observation of their work practice demonstrated that they were approachable, good communicators and were comfortable with individuals living at the Turrets who were at ease with them. There is always at least two staff on duty when the individuals are at home. Mrs Arnold is very often in the home when not officially on duty. She has a flat on the premises and covers the sleep in duties with her daughter. Each relative who responded by comment card said they felt there was ‘always sufficient staff on duty’. There is one staff vacancy at present, which the home hopes to recruit to shortly. Sickness rates remain very low. The home’s staff team covers any vacant hours due to holidays. The home has never used agency staff to cover shifts. Each member of staff has a personnel file. The files examined contain documents proving identity, contracts of employment, satisfactory references and enhanced Criminal Record Bureau Disclosures. The staff training records, which I examined, showed varying levels of training which staff had attended. However, there was no evidence that each staff member had completed all mandatory training such as First Aid, Basic Food Hygiene or Manual Handling. Whilst many of the home’s policies are explained to staff, there has been no significant accredited training provided since the last inspection. Also, staff appraisals have been introduced, but these remain inconsistent. I could not locate an appraisal for two staff members and another was last carried out in December 2003. It is recommended the home review this procedure as this will help to identify training or development needs for each staff member. Due to the size of the home and the small group of staff no formal supervision sessions or staff meetings are held. Such supervision as there is, remains informal and staff are able to discuss issues informally during their day-to-day work activities within the home. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements are simple and there are clear lines of accountability. The manager promotes a person centred approach and this is clearly communicated throughout the service. The views of the people who live in the home are sought and acted upon. A review of quality care is now conducted annually. There are systems in place designed to promote and protect the health & safety of both individuals and staff. However, Fire Safety must be improved within the home. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager, Mrs Arnold, has been the registered manager since 1995 and has a Bachelor of Education for people with special needs qualification. The deputy manager Ms Arnold has an NVQ Level 3, has completed the NVQ Level 4 care manager’s award and is currently undertaking a degree in social work. Ms Arnold developed and updated the home’s policies and procedures as part of course work toward the care managers award. These cover a wide range of procedues within the home including Adult Protection, Complaints, Finances, Training and Challenging Behaviour. Each policy had been reviewed during January and February 2006. The ethos of the service is clear. The philosophy of the home is that of an extended family, offering support and guidance within a secure framework and structured home life. Each individual I spoke with and those who responded by survey said they were ‘always treated well’ and the home ‘listened to them and acted on what they said’. Relatives who rersponded by comment card were complimentary towards the way the home is managed. One said “Mrs.Arnold provides an excellent care service” and another “we are very happy with the Arnold family’s care”. A review of quality care was carried out in May 2006. I was shown several questionniares, completed by each person who lives in the home and others by family members. These covered a number of areas such as Personal Care and Support, Daily Living, Management Issues an Catering/Food. Each person who lives in the home said they were either “very happy” or “happy” in each area covered by the questionnaires. Relatives said they were either “very satisfied” or “satisfied” with the home. The responses were evaluated and the review completed in June 2006. In general, the recording systems in place to support health and safety in the home are being used consistently. The home has a current Gas Safety Certificate and electrical wiring and portable electrical appliance checks are up to date. The home has a small number of generic Risk Assessments in place. These documents are well written and are regularly reviewed and updated. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 24 The home does not record the temperature of hot water outlets or fridge/freezer temperatures. The rationale appears to be that all individuals who live in the home can accurately check the temperature of hot water prior to its use and that the ethos is to promote a homely/extended family support. A Risk Assessments is now in place to support these practices. I examined the fire log. This showed the fire alarm system is tested on a weekly basis. Other equipment, such as emergency lighting, is tested each month. There are regular fire drills involving both the people who live in the home and staff members, however the names of people involved in each drill are currently not recorded. The home does not have a current Fire Risk Assessment in place, although this is being worked upon. Also, the home will need to develop personal emergency evacuation plans for individuals who would require support to safely evacuate the home in an emergency. The Turrets DS0000026618.V328066.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 3 2 X 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 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 2 X The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA35 Regulation 18(1) Requirement Ensure all staff are provided with training: a) In relation to promoting health and safety/safe working practices. b) To meet current, new and changing needs of each individual accommodated. 2. YA42 23(4) Fire safety must be improved: a) A Fire Risk Assessment must be completed and be subject to regular review. b) Names of each staff member and individual involved in a fire drill must be recorded. c) A personal emergency evacuation plan must be completed for each individual who requires support to evacuate the home in an emergency. 18/07/07 Timescale for action 18/02/07 The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA6 YA35 Good Practice Recommendations The home should continue to review its progress in providing information to each individual in a format which is accessible to them. The home should consider improving the system in place for appraising staff members. The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Turrets DS0000026618.V328066.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!