Inspection on 12/10/07 for Tramways

This inspection was carried out on 12th October 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tramways 16/09/08

Tramways 19/04/06

Tramways 17/01/06

Tramways 03/08/05

Tramways 19/01/05

Tramways 26/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Tramways Tramway Road Brislington Bristol BS4 3DS Lead Inspector Sandra Jones Key Unannounced Inspection 12th October 2007 09:30 Tramways DS0000026641.V353044.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 Tramways DS0000026641.V353044.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. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tramways Address Tramway Road Brislington Bristol BS4 3DS 0117 3009637 0117 9709301 max@aspectsandmilestones.org.uk admin@aspectsandmilestones.org.uk Aspects and Milestones Trust 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) Ms Nichola Richards Care Home 14 Category(ies) of Learning disability (14), Learning disability over registration, with number 65 years of age (14) of places Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 14 persons aged 65 years and over with Learning Disibilities for personal care only May accommodate up to 14 persons aged 40 to 65 years with Learning Disabilities for personal care only 19th April 2006 Date of last inspection Brief Description of the Service: Tramways is registered to accommodate up to fourteen adults with learning disabilities. The care home is operated by Aspects and Milestones Trust and at present there are two acting managers. The property was purpose built and arranged on one level, designed into two separate units accommodating seven people, linked by a passage, with a shared kitchen. It is situated in an industrial estate close to the Bath Road and within walking distance of shops, amenities and bus routes. Each unit has their own staffing with a manager, senior and home support workers. Tramways DS0000026641.V353044.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 over one day in October 2007 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from staff. The individuals at the home have profound learning disabilities and for this reason the interaction between staff and people at the home were observed to support judgements. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the AQAA and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Four people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. What the service does well: What has improved since the last inspection? The Trust has recognised that the location of the home restricts the individuals integration into the local community. A more suitable environment has been found and the people from Tramways will be moving. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 6 What they could do better: While staff endeavour to provide activities to the people at the home, activities are not meaningful and they are rushed. Staff take individuals to the shops each day and for short walks, these take place between tasks and they do not reflect the interests of the person. Meals have deteriorated, menus are not prepared and food is incorrectly stored. It is less likely that staff follow care plans because they are not up date, or they are not consulted. It is more likely that staff provide the care that they believe is right for the service user rather than what care plans say. There are ten requirements arising from this inspection. The Statement of Purpose must be reviewed to make clear the range of needs that can or cannot be met at the home. Formats must be accessible for the people that its intended, enabling individuals that wish to live at the home, their relatives and funding agencies to make decisions about living at the home. Care plans must be reviewed and the information must be up to date including the action plans for people with communications needs. Reports must show that individuals make decisions about their day-to-day lives. Risk assessments for people with mobility needs must be up to date. Members of staff must respect individuals rights to privacy and dignity. Members of staff must sign medication records immediately after administering medications. Medication profiles must be reviewed to ensure the information is up to date and accurate. Complainant’s level of satisfaction must be sought and where complaints are not resolved the complainant must be given to opportunity to seek redress from other sources. Since the last inspection there has been a significant reduction in the staffing levels. A review of the staffing levels must take place and copies of the review must be provided to the Commission. A Quality Assurance system must be introduced. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 7 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. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 8 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 Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 9 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 adequate This judgement has been made using available evidence including a visit to this service. In its present form the admissions procedure is unlikely to enable prospective new residents to make an informed choice. EVIDENCE: Individuals at the home have a Care Standards file, which contains copies of the Statement of Purpose, contracts of residency questionnaires and End of Life plans. However, the Statement of Purpose is not in an accessible format. The individuals at the home have communication needs and in the present format the individuals are not able to understand the content. The Statement of Purpose must be reviewed to provide an accessible format for the people for whom its intended and to fully describe the criteria for admission including the range of needs that can and cannot be met at the home. The people currently living at Tramways will be moving to a more suitable location, where they can be more integrated in the local community. Tramways DS0000026641.V353044.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 poor This judgement has been made using available evidence including a visit to this service. The care planning systems in place is not effective and the home is failing to provide an indivdiualised and consistent service. Individuals are not fully empowered to make decisions about aspects of their lives EVIDENCE: Each person has two files; one is labelled Care Standards and the other Personal Care Plans. Assessments of needs were conducted by placing agencies because individuals will be moving to more suitable environment. The assessments conducted ensure that the staff at the home can meet the individuals changing needs. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 11 Each person has a daily routine plan, which specifies the preferred routines for getting up, personal care, meals and “What I like to do in the morning, afternoon and evening plan.” There is an expectation that staff read and sign care plans to indicate their awareness and to confirm that the plans will be followed. Members of staff said that they have no input into the care planning process so they do not contain the staff’s knowledge of the persons needs. Staff said they do what they believe service users need rather than follow the care plan. Communication needs form part of the individuals Personal Care Plan. Through the “Listen to me” charts that specify the behaviours exhibited, staff are informed on the way that individuals make decisions about aspects of their lives. The staff on duty at the time of the site visit said that there was an expectation that staff add information to the chart. However, staff said that they were not shown how to compile the information. Members of staff said that the people at the home do not use verbal communication and explained the way individuals are supported to make decisions. Initially individuals are asked and if they refuse the person is not pressurised to undertake the activity. In terms of clothing individuals are given a choice of two items of clothing, food likes and dislikes are known but if the meal is pushed away it is an indication that an alternative may be needed and staff respond. There is a keyworker system and the staff say that the keyworker role entails supporting individuals with their day-to-day needs, maintaining the persons appearance and enabling people to live their chosen lifestyle. However, members of staff were not aware that a Keyworker policy is in place and there are clear discrepancies between the policy and the staff’s understanding of the role. For example the policy says that staff will be involved in the care planning process but evidence indicates that they are not. Therefore there is a risk that staff may not all be meeting needs in the same way. Members of staff use a communication book to pass messages from shift to shift and generally relate to housekeeping tasks and staffing levels. A house diary is used for appointments and tasks to be undertaken on specific days. Daily reports are used by the staff to record meal times, the times individuals rose, retired and activities undertaken. However, the decisions made the person are not included within the diaries. Individuals at the home are restricted from entering the kitchen, leaving the property and entering staff areas. Risk assessments are in place for activities that may involve an element of risk. These include leaving the building without staff support, fire risk assessments and community access. Specific risk assessments that focus on moving and handling, bedsides and “when required” medication protocols are also in place. Members of staff said that two people have moving and handling needs and two need some guidance with walking. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 12 Following from a fall one person must have two staff to support the person with transferring and is using a wheelchair while a special chair was ordered, the other person’s mobility needs relate to behaviours and two people use grab rails and support from staff to move around the home. Reports of accidents and incidents involving the individuals at the home are maintained. Tramways DS0000026641.V353044.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 poor. This judgement has been made using available evidence including a visit to this service. Support systems are poor and individuals have little opportunities to lead active and interesting lives. The provision of properly planned nutritious meals has deteriorated Service users’ rights to dignity and individuality are not fully protected. EVIDENCE: The individuals chosen lifestyle is integrated into their Personal Care Plans. There is a rota of the activities undertaken by the people at the home and the rota shows that with the exception of one person the people at the home have twice weekly day care sessions for two hours. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 14 The staff said that the Women’s Education Association (WEA) undertake 1:1 community-based activities with people at the home. Visiting shops and galleries and aromatherapy are some of the activities undertaken. Staff also said that they organise trips, holidays and visit local shops with people at the home. It was further stated that sometimes 1:1’s are prearranged and other times it occurs as the situation arises. At the time of the inspection it was observed that individuals were going out to shops with staff. The people at the home have little opportunities for integration within the local community because the area is hilly and walking with individuals or assisting wheelchair users is difficult. There is a home’s vehicle, which is used for trips, shopping and to visit friends and family. The visiting arrangements for the home are included within the Statement of Purpose. The staff said that three people have visitors from friends and family and staff support individuals to maintain contact with family by providing transport. There is a Dignity and Privacy policy is place and describes the actions to be taken by the staff to respect individuals rights. Members of staff were consulted about the way individuals are respected. Staff said that while bedrooms are lockable, individuals do not have keys and closing bedroom doors prevents individuals from entering other people’s bedrooms. For individuals that have mail, staff said that the person’s permission is sought and if there is no response the envelope is opened and read to the person. It was further stated that the individuals permission is sought to discuss information in front of them. Keyworkers also said that when they are tidying bedrooms the person is taken to undertake the task. Taking the person to purchase clothes that is age appropriate also values the person because appearance is as important. Members of staff decide at each mealtime the meals to be served as there are no menus and no cook to forward plan. It is evident that there has been some reduction in the quality of the meals served at the home. Food kept in the fridge was found not dated and while fresh food was available there has been an increase in convenience food. Since the last inspection, the cook is no longer employed and there are no plans to replace him/her. Support workers now have the combined role of cooking, caring and cleaning. During the site visit a member of staff was observed not seeking the individuals permission before putting plastic aprons over people’s heads. This person was also observed putting sugar in the cups of tea of the people at the home. When asked if all the people at the home took sugar, the member of staff said they had been instructed by the manager to put sugar in everyone’s tea. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 15 While staff endeavour to provide activities to the people at the home, activities are not meaningful and they are rushed. Staff take individuals to the shops each day and for short walks, these take place between tasks and they do not reflect the interests of the person. Meals have deteriorated menus are not prepared and food is incorrectly stored. Tramways DS0000026641.V353044.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. People may not get the care they need as records are conflicting Health care needs are appropriately met by referrals from the homes staff to other professionals Medication systems are not safe. EVIDENCE: Personal care needs form part of the daily routines of the Personal Care Plans (PCP). The information is specific about the individuals likes, dislikes and preferences about the way personal care is to be provided. The times that the individuals rise and retire are recorded in the daily diaries, which show that staff follow the routines. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 17 PCP’s have a health action plan, with health concerns and where appropriate guidance to staff on the actions that must be taken to maintain a healthy lifestyle, are included. Within the health action plans, the behaviours exhibited when the person is unwell is included. During the site visit the staff were consulted about the way one person will exhibit signs of pain. Members of staff said the person would be very quite, which contradicts the PCP which says that the person becomes louder when in pain. Documentation from heath care professionals show that individuals are invited for routine screening and because of their level of needs invitations are generally refused. Other documentation in place confirms that referrals for professional support are sought through the Community Learning Disability Team (CLDT) for Speech and Language therapists and input form the psychiatrist. A record of multiagency visits is maintained and staff record the outcome of GP’s and other health care professional visits. Records also show that individuals at the home have access to NHS facilities, individuals have regular check-up with the optician and dentist and the chiropodist visits the home. Members of staff said that diaries and communications books ensure that medical advice is consistently followed. However, one person said that it could be better flagged up. Mobility needs are also included within the individuals PCP and it is clear that information is not up to date. One person requires assistance from two staff with moving and handling. However, the care plan has not been amended. Also staff said that this individual has physiotherapist involvement and this information is missing from the care plan. It is acknowledged that more up to date information is on display in the persons bedroom. Staff were not following the written advice. Medications are administered from a monitored dosage system. The picture of the person and the way they take their medication is included in the medication administration records. It is evident from the gaps in the recording that records are not always signed after administering medication. A record of medications no longer required is maintained which the pharmacists stamps to indicate receipt of the medication for disposal. Where individuals have medication concealed, consent from their next of kin and health care professionals was sought. Documentation states that the medication is essential and it would be in the persons best interest to have the medication. Medication profiles lists regular prescribed medication, its purpose and side effects. “When required” medication profiles lists the reasons for taking the medication, side effects and other information to be taken into account. The profiles are clearly not up to date and must be reviewed. Current medication was not in the profiles. Tramways DS0000026641.V353044.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 adequate This judgement has been made using available evidence including a visit to this service. Complaints are not dealt with in a satisfactory way. EVIDENCE: Copies of the Complaints procedure are included within the individuals files. However, the formats are not accessible so that the people for whom its intended can understand it. Two complaints were received at the home since the last inspection. One relates to the reduction of one person’s day care provision and the other is from a member of the public relating to the behaviour of a staff member escorting service users outside the home. The records of complaint do not currently include the complainant’s level of satisfaction. The level of satisfaction must be sought to show the effectiveness of the homes investigation. this would also indicate whether, in the case of a dissatisfied complainant the complaint should be investigated at another stage of the procedure or by a separate organisation. Polices and procedures that establishes the commitment towards safeguarding adults from abuse include Protection of Vulnerable Adults, “Do The Right Thing” and Complaints procedure. The Protection of Vulnerable Adults defines the principles of abuse with instructions of the actions to be taken where incidents of abuse is suspected which follows “No Secrets” guidance. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 19 The “Do The Right Thing” provides guidance on the steps to be followed for reporting poor practice. Members of staff said that Safeguarding Adults training is part of the introductory package for new staff and new staff must attend this training. Tramways DS0000026641.V353044.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 Trust has recognised that the property is not suitable and the current individuals will be moving to a more suitable environment. EVIDENCE: Tramways is purpose built for fourteen people with learning disabilities. The accommodation is arranged into two houses with separate entrances with a link between the two houses. Each house has seven bedrooms and its own toilets, bathroom and lounge and share the kitchen and laundry. The property is sited within an industrial estate with close access to residential community. Shops, restaurants, bus routes and amenities are within a short walking distance. While there is level access into the home the local environment is hilly. Since the last inspection, the people living in house 2 have moved out and the organisation is using this house for short-term care. The people in house 1 will be moving out because there is little connection with the local community because the individuals have mobility needs and the area is hilly. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 21 While the individuals currently moving out, the property will change purpose and accommodation will be offered to another group of people. A tour of the property took place and the property is clearly in need of repair and redecoration. In the dining room, the walls and ceiling are in need of attention, corridors are shabby, some bedrooms have holes in the walls and paint is peeling. The laundry room is painted and the flooring is vinyl for easy cleaning. In the laundry room there is a domestic washing machine that can reach 95 temperatures and two domestic tumble dryers. Tramways DS0000026641.V353044.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 poor This judgement has been made using available evidence including a visit to this service. The staffing arrangements mean that the care of individuals is not person centred. EVIDENCE: The rota in place shows that three staff are rostered throughout the day. It is noted that since the last inspection staff have combined roles of caring, cooking and cleaning for seven adults. As mentioned above this has impacted on the provision of meals and the quality of individuals’ lifestyles. In addition staff were observed treating individuals in an undignified manner and in an institutionalised way. Bank and existing staff, where possible, cover vacancies and agency workers are only used on occasions that bank and permanent staff cannot cover the shift. There is a bank file that includes emergency contacts, individuals profiles and house plans, with medication profiles and local policies. Profiles are clearly out of date and recent changes in individuals needs are not included. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 23 There was no access to staff files at this inspection therefore recruitment procedures were not inspected Tramways DS0000026641.V353044.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. Individuals can expect to live in a safe environment. For individuals to be re-assured that standards will be the subject of ongoing monitoring, Quality Assurance systems must be introduced. EVIDENCE: Facilities exist for the safekeeping of cash and valuables on behalf of the people at the home. Cash is held on behalf of the people at the home and staff check cash balances when shift changes occur. From the observations of the checks, the records cross-referenced with the balances of cash held at the home. Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 25 Representatives of the responsible individuals conduct monthly visits and report on the conduct of the home through Regulation 26. Staff on duty say that it is rare for their feedback on the conduct of the home to be sought. Fire Risk assessments were completed by the manager and must be reviewed to maintain a safe environment for the people at the home. Within the risk assessments checks, training and practices were identified as measures that prevent fire at the home. The Quality Assurance system was not available for inspection. Certificates from competent contractors that evidence compliance with other legislation was not available during the site visit. Tramways DS0000026641.V353044.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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 1 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 2 x LIFESTYLES Standard No Score 11 x 12 1 13 2 14 x 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 x 2 x x 3 x Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 27 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 6 Requirement The Statement of Purpose must a) be reviewed to make clear the range of needs that can or cannot be met at the home. b) Formats must be accessible for the people that it’s intended. Care plans must be up to date a) Reports of individuals communications needs of the people at the home must be accurate b) evidence that individuals make decisions must be provided. Risk assessments for people with mobility needs must be up to date. Individuals right to Privacy and Dignity must be respected. The quality of the food provided must improve Medication records must be signed immediately after administration, b) Medication profiles must be reviewed. Complainant’s level of satisfaction must be sought and where complaints are not resolved the complainant must be given to opportunity to seek DS0000026641.V353044.R01.S.doc Timescale for action 30/03/08 2. 3. YA6 YA7 15(2) 17(1)(a) Sch.3.l 30/12/07 30/12/07 4. 5. 6. 7. YA9 YA16 YA17 YA20 13(4)(b) 12(4)(a) 16 (2)(i) 13(2) 30/11/07 30/11/07 30/11/07 30/11/07 8. YA22 22 30/11/07 Tramways Version 5.2 Page 28 redress from other sources. 9 YA33 18(1)(a) A review of the staffing levels must take place and copies of the review must be provided to the Commission A Quality Assurance system must be introduced. 10/11/07 10 YA39 24 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Tramways DS0000026641.V353044.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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