Inspection on 13/09/06 for Underhay House

This inspection was carried out on 13th September 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Underhay House 16/07/08

Underhay House 03/08/07

Underhay House 26/01/06

Underhay House 19/07/05

Underhay House 27/02/05

Underhay House 28/09/04

Underhay House 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Underhay House 639-641 Muller Road Eastville Bristol BS5 6XS Lead Inspector Sarah Webb Key Unannounced Inspection 13 , 15 , 29 September & 2nd October 2006 09:00 th th th Underhay House DS0000026624.V317566.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 Underhay House DS0000026624.V317566.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. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 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) Freeways Trust Ltd Miss Claire Anne Hayward Care Home 12 Category(ies) of Learning disability (11), Mental disorder, registration, with number excluding learning disability or dementia (1) of places Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Underhay House is a care home that is registered with the Commission for Social Care Inspection to provide personal care for up to twelve persons, eleven with a learning disability and one specific person with a mental disorder, all aged between 18-64 years. The home is operated by Freeways Trust Ltd, a non-profit making organisation that has a number of care homes within the local area. There is a satellite home for three people at 224 Glenfrome Road that is close to Underhay House and which is registered with the Commission for Social Care Inspection. Both homes are managed by the same person Ms Claire Hayward. The accommodation comprises of two mature terraced houses based over three floors. Access to the upper floors is by means of stairs only. The home is situated in a residential suburb of Bristol on a busy road. Public transport is available close to the house and there are local shops opposite as well as a large supermarket within a quarter of a mile of Underhay House. Underhay House is within quarter of a mile of the M32, an urban motorway that links to Britains motorway system. Underhay House also accommodates a pet cat. Underhay House DS0000026624.V317566.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 inspection, conducted over 11.5 hour, with the focus on checking the progress of the requirements and recommendations from the unannounced visit in February 2006. Although the environment, alongside cleanliness, has improved since previous inspections, there are still some areas that are in need of improving. In addition to this key records were examined, including health and safety and care planning documents. A requirement is partly met in relation to care planning. Three further requirements have been met leaving one partly met. One recommendation has been met leaving one that is also partly met. Further evidence was gained through discussion with staff and residents and through examination of records. Those residents spoken with said they were happy living at Underhay House and felt well supported by staff. Comments received from 5 families were positive stating that they were well informed of their relatives care and that staff were ‘open’ and approachable. What the service does well: What has improved since the last inspection? A requirement for the development of care are plans have been partly met with health action plans also being implemented. The organisation has developed a quality assurance tool. The home has worked hard to redecorate residents’ bedrooms. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 6 The home has repaired the shower and redecorated the bathroom on the first floor. The home has an accurate stock record of all medication. 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. Underhay House DS0000026624.V317566.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 Underhay House DS0000026624.V317566.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): 2,3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to being admitted to the home, and are referred for reassessment if their needs change and the home is no longer able to support them fully. Residents’ benefit from introductory visits to the home in order for a choice to be made. EVIDENCE: Residents care files were examined; these included residents’ agreement, assessment carried out by home, and both assessment and care plan provided by individuals placing authority prior to their placement. The manager said the home has requested urgent reviews for four residents with their placing authority due to their changing needs. These are to take place in the near future. ‘Freeways’ organisation has an admissions procedure that is followed by the home; this was evident through discussion with the manager and residents application forms in place. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 9 The two most recent residents admitted to the home had appropriate information given to them informing them about their new home. An “Introduction to New Home” and “Welcome to New Home” booklets include day to day routines and information, and essential procedures such as using house equipment. The manager said a resident who was due to move into the home had made frequent visits to the home prior to their intended date of placement including overnight stays in order to decide whether they considered this was the right choice of home. On these visits they met the other residents and staff and had discussion about the decoration of their room. This is good practice. Although the visits are logged in the daily diary notes with other ongoing information it was advised that an ongoing record is also kept in their care files to evidence individuals are supported in making choices regarding their new home and that this can be case tracked more easily. The manager also said the home will contact other agencies and family members if needing specific information about a new resident; an example was given of a follow up with a family regarding a new residents food preferences and in meeting their cultural needs. Two residents have a hearing impairment whilst one also has a visual impairment. One resident has needs that have changed, whilst the other has specific communication needs. A staff member was observed communicating with one of these residents through signing. However discussion with another staff member identified that there were occasions when they felt this person’s communication needs were not being met due to not all staff signing. The manager said this resident has been supported through an interpreter on differing occasions and staff were due to attend a signing course but it had been cancelled. Through observation of these residents care files it was evident that the manager is aware that the home no longer has the capacity to meet their needs in full and is proactive in ensuring their needs are reassessed in order to offer other more suitable placements. Underhay House DS0000026624.V317566.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): 6, 7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care planning is in the process of being implemented as are health action plans. Residents are supported in making decisions and taking calculated risks in all aspects of their lifestyle. EVIDENCE: Selections of residents care files were examined. A requirement has been partly met for the homes care plans to be implemented. The manager has started to produce care plans for residents in order to inform staff of individuals’ needs and how these should be met. She is aware of the need to continue to develop the care planning process and complete all residents plans. A recommendation is made for outdated paperwork to be backfiled or transferred to another file in order that relevant and ongoing information is easily accessible. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 11 Annual reviews take place where all aspects of residents’ lifestyles are discussed. These were comprehensive records and provided clear detailed information how individuals had progressed with their aims for the future year. Records demonstrated that residents are fully involved with this process along with significant people in their lives. Not all residents’ reviews had been signed and dated; a recommendation is made for these to be signed and dated in order to monitor how individuals progress. The home operates a key working system whereby each resident has a named member of staff who plays a key role in co-ordinating the services they receive. Monthly key worker meetings take place evidencing regular monitoring of residents care. A staff member spoken with said that the staff team was good in building and maintaining relationships with residents. This was observed whilst staff communicated positively withy individuals involving them in discussion and listening to them. Through discussion with residents and observation of records it was evident that they made differing decisions about their lifestyle including choice of food to attending various activities and in the routines of the home. A resident also explained their involvement as an active member of a Bristol advocacy group and attends regular meetings and activities. Individual risk assessments were available, including accessing the community, handling finances, support with personal care, travel arrangements, and activities in the home. The majority of those risk assessments examined were up to date and had been reviewed; there were a few that are in need of a review. Risk assessments demonstrated that residents are encouraged to take risks according to their differing abilities within safe risk management practice. This is good practice. Underhay House DS0000026624.V317566.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): 12, 13, 15, 16, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to lead full and active lifestyles and are supported by staff to access leisure opportunities in the community. Their rights are respected and they are encouraged to take responsibility in their daily lives. EVIDENCE: Residents and staff gave examples of how individuals are involved in making choices about their lifestyle and social preferences. Leisure opportunities occur regularly either through accessing other homes, within the organisation, as a base for activities or day trips supported by the homes mini bus. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 13 A resident said they had been out over the weekend for a trip to Cardiff that they said they had enjoyed. Other residents said they enjoyed going shopping locally. Residents are supported to attend meaningful opportunities including Leigh Court (a Freeways day service), college, and working placements. This was further evidenced in individuals care records. The home has a computer which residents were observed to be using for their leisure. Residents have benefited from going on holiday this year; residents spoken with said they had been involved in deciding which holiday suited them best. Residents are supported with intimate personal relations and are approached sensitively and appropriately. The manager gave examples of good communication and consultation between the home and families taking into consideration the need to respect residents’ confidentiality. Discussion also with staff, residents and records provided evidence that individuals are encouraged to maintain links with families and friends and that some residents visit their family at regularly. It was evident from this visit to the home that individuals are involved in the daily routines of the home. Residents were observed getting up when they wished and were independent in getting themselves food and drinks. Residents said they helped with general household chores including cooking, clothes washing and the cleaning of their bedroom. They were keen to show the weekly rota of tasks designated to individuals. The home keeps a record of food offered and any alternatives. Menus examined indicated that residents are offered choices with healthy eating options. Underhay House DS0000026624.V317566.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, & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are supported to lead healthy lifestyles with their healthcare needs being monitored well. The administration of medication is well controlled with clear instruction; however consent needs to be obtained from residents. EVIDENCE: Examination of residents’ healthcare records evidenced that individuals’ physical and mental healthcare needs were being met through regular reviews of medication and support from appropriate professionals. There was also documentation indicating both guidance and training is offered to staff through specific healthcare professionals and agencies. The home has started recording health action plans for residents. These included information about others involved in individuals’ healthcare and action Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 15 for supporting residents with their personal support needs, eating healthily and medication. The organisation has a policy and procedure for the administration of medication. There is also an in house policy. These outline the protocols for the administration, recording, ordering, disposal and self medication processes. It was evident through the observation of records that the home has appropriate systems in place for the safe administration of medication. There are 9 residents who have medication administered. Medication profiles recorded individuals’ medication needs. There is I person who self medicates whilst another is in the process of being supported towards self medication through an action plan. However there was no documentation stating that residents have consented to medication being administered; therefore a requirement is made for the home to keep a record of consent for all those requiring support with the administration of medication. The home has procedures in place for monitoring staff competency in the administration of medication; new staff initially shadow those deemed competent and are then observed through the medication process. There are appropriate procedures for the medication to be sent to day services and when residents take social leave. The Commission has received two Regulation 37 reports with regard to medication errors. This was discussed at this visit and the manager and assistant manager evidenced action that has taken place. Underhay House DS0000026624.V317566.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 & 23 Quality in this outcome area is good. Residents can be confident that they will be listened to and that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Freeways organisation has a formal complaints procedure; residents have been given an accessible copy of the procedure explaining how people can complain. It also includes appropriate contacts and timescales to respond to any complaint. Residents spoken with indicated that they knew who they could go to if they had any concerns and complaints. It was evident through observation and discussion with both residents and staff that residents feel confident to express their views or raise concerns either through house meetings or care reviews. All complaints are logged and with action and outcome recorded. Those families spoken with who have made complaints said they were happy both with the way the complaint was dealt with and the outcome. The organisation has a policy on the protection of vulnerable adults. All staff are trained in abuse awareness within their induction period. Staff are also trained through local authority courses and by the manager who is a trainer in this area. The organisation operates safe financial systems for the administration of residents finances. This is followed by the home with specific controls in place Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 17 that are adhered to. During this visit a Regulation 26 visit was made by the Principal Care and Development Manager. A copy of the report is sent to the Commission on a quarterly basis. These visits demonstrate that the organisation monitors all aspects of residents care. Care plans included positive strategies for dealing with challenging behaviour including triggers and techniques for supporting individuals giving staff clear guidance. Staff are trained through both Learning Disability Award Framework and a specific external trainer in recognising triggers in order to defuse situations that may be challenging. Examination of records indicated that the home involves appropriate professionals in supporting both staff and residents. Underhay House DS0000026624.V317566.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, & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although residents benefit from living in a clean and homely environment there are still some key areas that are in need of improving in order that the health and safety of both residents and staff. EVIDENCE: Underhay House comprises of two terraced houses based over three floors and in keeping with the local neighbourhood. The house is situated on a busy main road in a residential suburb. There are good public transport links to the City Centre and surrounding areas. Amenities are close by including a large supermarket and shopping complex Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 19 Since the last inspection the home has now employed a cleaner. Although they had only just recently started in post it was evident that they have made an impression in areas of the home that are already showing improvements to the cleanliness of the home. Staff have decorated several residents bedrooms; those seen were decorated individually with personal items displayed. There are 3 bedrooms that are still in need of decoration; two of these are to be completed by the organisation’s maintenance department. There are still some areas that are in need of decoration including a relaxation room on the top floor; a small area of plaster is in of repair in the laundry room. Although the carpets have been cleaned in the lounge and conservatory, the appearance of the latter was still of a stained appearance. The manager said that carpets are cleaned regularly but due to the conservatory being the dining area and a communal walkthrough to the kitchen and other areas of the home, it was a difficult area to manage. Discussion was had with the manager regarding a review of the flooring in this area in order to replace the carpeting within a maintenance programme. However there was no evidence that the home has a planned maintenance programme for the refurbishment and redecoration of the home. Therefore a recommendation is made for this to be implemented. It was also evident that the lighting in the conservatory was unsatisfactory. A resident with a visual impairment is having difficulty in seeing what he is eating; this was evidenced through discussion with staff and through a regulation 26 visit where it had been entered as a maintenance requirement. There are also concerns that the medication is issued from this area; although there have been no medication errors identified due to bad lighting as yet, the home needs to ensure prevention of such incidents. Therefore a requirement is made for the lighting in this area to be improved. Although a ventilation system has been installed in the kitchen, and this has recently been reviewed, there are still considerable problems. Staff said the summer months were unbearable in the kitchen with both residents and staff feeling the effects of the heat. A requirement is made for a better ventilation system to be put in place ensuring the health and safety of both residents and staff. Staff have worked in the garden during the summer months to improve its general appearance. Underhay House DS0000026624.V317566.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, 34, & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Competent staff support residents, however, the home must ensure there is evidence in the home of a thorough recruitment procedure being undertaken. EVIDENCE: There are three staff with an National Vocational Qualification 3 or a nursing qualification. There is no change in that once staff complete the Learning Disability Award Framework, they then proceed on to registration for National Vocational Qualification. Currently there are a further three staff who are in the process of completing Level 3 whilst a further two are to commence shortly. The home currently has one vacancy with two staff due to leave shortly. Interviews were taking place during this visit with the involvement of a resident on the interview panel. This is good practice for residents to be involved in the homes recruitment practice. Six staffing records were examined; these provided evidence that staff are police checked through the Criminal Records Bureau, that staff complete application form, and two references are sought. Records indicated that two Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 21 references had been received for staff bar I person where a reference was uncompleted. The home must ensure that if references are deemed unsatisfactory that further references are sought, or provide evidence that they have followed the organisations recruitment policy in order to ensure the protection of residents. Staff records should also include proof of identity through a photograph. Through observation of staff records it was evident that there is an ongoing issue concerning a working visa for a staff member; discussion was had with Freeways who are dealing with this through the appropriate authorities. Training records identified that staff have attended first aid, food hygiene, medication, manual handling and health and safety. Other areas also covered challenging behaviour, mental health, and autism. A staff member was concerned that they needed to be provided with more information and training in relation to resident in order to meet their needs. The manager said she is aware that this is an area that can be improved and has invited a specialist service to attend staff meetings in order to support staff. Induction checklists identified that staff are instructed in day to day, and essential procedures of the home, and house security. Discussion with the manager also identified that she will seek to address difficult issues. She organised for a staff questionnaire to be sent out relating to racism. The manager is now addressing issues that were highlighted in the findings. This is good practice. Underhay House DS0000026624.V317566.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, 39, & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run so residents can be confident that their rights and welfare will be safeguarded. However, the home needs to improve in some areas of health and safety in order that both resident and staff are kept safe. EVIDENCE: The registered manager, Miss Hayward has run the home for a number of years and has proved herself competent in all aspects of the running of the home. She has numerous qualifications and displays a good awareness of her responsibilities under the Care Standards Act. These include qualifications in NVQ 4 in care and management and an NVQ 3 in training and development. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 23 She is also an NVQ Assessor and keeps up to date by attending periodic training. Those staff spoken with stated that all the management team are very approachable with this ethos extending to residents and their families. This view was also evidenced through discussion with four families who clearly stated that they had an ‘open’ relationship with staff who involved them in the care of their relative and that the staff support residents well. The organisation has recently produced a quality assurance tool meeting a requirement from the last inspection. This has yet to be implemented; the organisation are to pilot this and receive feedback prior to sending out to all services. The home currently seeks the views of residents through a series of meetings including those at review, key worker and house meetings. Fire training records indicated that annual fire training has been late; discussion with the manager and records evidenced that this will be carried out shortly. Records also identified that not all staff have had regular fire drills, therefore a requirement is made for this to be implemented in order to ensure the safety of residents and staff. Fire maintenance records indicated that fire equipment is inspected on a regular basis by contactors. The last fire inspection advised for a risk assessment to be carried out; this has been implemented. The home informs the Commission through regulation 37 reports of both incidents and accidents relating to the health and welfare of residents. The home also informs the Commission of any ongoing issues that are being dealt with. Day files record residents’ welfare and daily activities and communication between staff was seen through diaries; all confidential records are stored appropriately. Those records seen have been recorded previously in the text of the appropriate standard apart from a requirement to update residents’ inventories. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 24 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 3 26 3 27 3 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 2 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 3 x 3 x 3 x x 2 x Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard YA9 YA10 YA28 YA28 YA34 Regulation 12(1)(a) 13(2) 23(2)(p) 23(2)(p) Sch 4.6 Requirement Update risk assessments. Keep a record of all residents consent to the administration of medication. Improve the lighting in the conservatory/dining area. Improve the ventilation in the kitchen. Ensure that if references are deemed unsatisfactory that further references are sought, or provide evidence that the organisations recruitment policy is followed. (2)Staff records to include proof of photographic identification. Ensure all staff are involved in regular fire drills. Update residents inventories Timescale for action 31/01/07 30/11/06 31/01/07 31/12/06 03/10/06 6. 6. 7. YA34 YA42 YA41 Sch 4 23(4)(c) Sch 3 31/12/06 03/10/06 31/12/06 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 Good Practice Recommendations DS0000026624.V317566.R01.S.doc Version 5.2 Page 26 Underhay House 1. Standard YA6 2. YA24 (1) Backfile outdated paperwork or transfer to another file in order that relevant and ongoing information is easily accessible. (2) Sign and date appropriate paperwork such as residents reviews. (1)Implement a formal maintenance programme for the refurbishment and redecoration of the home. (2) Review the flooring to the conservatory to consider other means of flooring for the dining /walkway communal area. Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 27 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 Underhay House DS0000026624.V317566.R01.S.doc Version 5.2 Page 28 - 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. 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