Inspection on 28/11/05 for Whites

This inspection was carried out on 28th November 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Whites 17/05/07

Whites 10/04/06

Whites 04/05/05

Whites 19/06/04

Whites 13/03/04

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 Whites Station Lane, Muller Road Horfield Bristol BS7 9NB Lead Inspector Nicky Grayburn Unannounced Inspection 09:30 28 & 29th November 2005 th Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 Whites DS0000026557.V263715.R01.S.doc Version 5.0 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. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Whites Address Station Lane, Muller Road Horfield Bristol BS7 9NB 0117 951 6407 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 Mr. Gerald Padfield Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 Brief Description of the Service: Whites House is operated by Freeways Trust Limited and is registered to provide accommodation and personal care for up to eleven people who have a learning difficulty. Primarily they accommodate people who have complex behaviour that can challenge the service provided. The home itself is situated in large grounds, which is set apart from a busy main road. This provides a secure area to which residents can have unlimited access. A cat also lives at the property. It is close to local amenities, including shops and public houses. It is also near to a main bus route. Whites benefit from having a van that is regularly used by residents to access community facilities. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over two days. On the first day, the inspector focused on the environment; previously made requirements and recommendations; and spent time with the deputy manager and some of the residents. On the second day, the deputy manager came in specifically, and the inspector spent more time staff, residents and looked at documents kept at the home. The Deputy confirmed that service users prefer to be referred to as residents. Verbal feedback was given to the deputy and team leader at the end of the inspection. What the service does well: What has improved since the last inspection? Two of the three requirements regarding furnishings within the home had been met entirely. The third requirement referring to keeping accurate records of finances had been improved but still requires attention. There have been fewer notable incidents evidencing that residents are becoming even more settled and the staff are supporting their behaviours more effectively. A new deputy has been appointed ensuring that the manager is supported in various tasks, and staff are now better supervised improving the care given to residents. The day services/activities has developed offering residents a choice of what to do if they do not attend Leigh Court. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 Residents are assessed prior to admission and can ‘test drive’ the service before deciding to live there ensuring that the home can meet their needs. Contracts must reflect current agreements so that the residents are aware of the terms and conditions of living at Whites. EVIDENCE: There have been no new admissions to Whites since the last inspection. Initial assessments are in place for each resident. It was unclear as to how Whites organise their contractual agreements with residents. This was discussed with the Deputy Manager. Service user guides were found in some of the Lifestyle Plans, which also combines the contract for living at Whites. There are also some ‘Resident’s Agreements’ which are kept in the individual files. Some of these date from 1992, 1997. Some of the Service User Guides were not completed, in terms of how much money they have to contribute and which room is theirs. There is not a consistent system in place to ensure that residents are aware of their terms and conditions. It is required for these to be consistent and to reflect current agreements between Freeways and the resident. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 9 The ‘Client Enquiries and Admissions Procedure’ policy is clear and details the process of any admission. It states the home would send their brochure, an application is to be completed; a home based assessment would be undertaken; visits and an overnight stay is then arranged with further tea visits if necessary; induction to the home; and then reviews after the first and third month. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Individual plans are comprehensive, being reviewed every six months ensuring any changes of need are met. Risk assessments and reactive strategies need to be reviewed to ensure they reflect residents’ current lifestyle and personal goals. EVIDENCE: Five Lifestyle plans were examined and contained monthly reports, which are written by their key workers. The majority were up-to-date and included much detail concerning the previous month to monitor any progress made. However, some had no entries since August 2005. It is recommended that Key Workers fulfil their role of completing the monthly reports. Six monthly reviews of care plans occur with evidence of family members having been invited. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 11 It was evident in certain files that some resident have advocates who visit the resident. Residents have the opportunity to participate in regular meetings There are risk assessments and reactive strategies in place to prevent challenging behaviour and to encourage positive behaviours for certain aspects of residents’ lives. However, whilst going through some of them with the deputy it was evident that some have been recently up dated, but some are in need of review to ensure that they reflect current lifestyles and behaviours. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 15, 16, 17 Residents are able to maintain contact with relatives and friends with support from staff. Residents benefit from support to access the local and wider community. Professional consultation and nutritious cooking would benefit residents to maintain a healthy diet. EVIDENCE: Some of the residents attend Freeways Leigh Court Day Centre. Some residents will be starting to go for one day per week in the near future. There is an improvement from the previous inspection regarding the on-site day service. This is held in the porta cabin in the garden. There is a programme for all of the residents and the record of the activities was looked at. However, when staff shortages occur, the services are postponed (refer to Standard 33). Further, the environment of the cabin does not have an inviting presence. It addition to the day services, residents have a life skills day whereby they are supported to carry out daily chores. This will be a focus of the next inspection. Whites won the competition for their display of their home this year at the open day made by the residents with staff support. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 13 As part of the programme, some residents partake in sessions called ‘local community’ and ‘explorer’. Staff said that they go out in the van and explore parts of Bristol and where the residents have lived in the past. It was noted from documents that residents use the facilities in the local and wider area such as the bowling, pub, aerobics classes at a local sports centre, shopping, and going for walks. It was observed that residents could pursue their personal hobbies and interests within the home. Staff confirmed that three different holidays have been taken this year with different residents to Butlins, Minehead; Croyd Bay, Dorset; and Crantock Bay, Cornwall. Within care folders, details of family relatives are recorded. Some residents have specific contact arrangements, which are noted in the diary to ensure they occur. However, it read in the communications book that staff need reminding to maintain the routine. The Deputy was aware of all resident’s family contacts. Some residents do not have any contact with relatives. Arrangements are being made for the festive period for some residents to spend time with family. Morning and evening routines are written up detailing how they wish to live their lives on a daily basis. It was observed how some residents have their own keys to their bedrooms to retain privacy. Throughout the inspection, staff and residents interacted positively, and residents spent much time in the shared spaces within the home. There is a restriction with accessing the kitchen facilities due to presented risks. The weekly menu was on display in the kitchen. It showed predominantly traditional English foods, with a roast dinner on Sundays. Due to some obsessive behaviours, all storage units for foods are now kept locked. The second kitchen held limited fresh produce, and a lot of snack foods. The inspector was told that some residents are on diets, using ‘weight watcher’ meals, and staff said they have the meals ‘only 5-6 times a week’. Staff could not verify which residents were on the diets. No care plans or input from a dietician or GP has been obtained. Staff said that the residents’ meals are supplemented with fresh vegetables when they are on the menu. Weights are monitored. Staff would benefit from having training to be able to cook meals with the correct portions. Residents can choose to eat at either of the dining room tables or on the sofas. Staff eat with the residents, and have their food provided by the Trust. It is required for staff to gain input from the resident’s GP and a dietician to ensure that residents are eating a nutritious and healthy diet. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Personal care is given with dignity and support when necessary. Residents are safeguarded from a robust medication system. EVIDENCE: Within the files looked at, there is a lot of information about the resident. There are personality and communication profiles detailing important and essential information about how to care and support the resident. It was observed how residents could get up when they want and dress in their own style. Residents have detailed plans ensuring that staff are aware of their preferences and needs. A daily checklist is in place to ensure that all residents receive the support they need, i.e. shaving and washing. Staff training in communicating with Makaton would further benefit the residents due to the number who use and/or could use Makaton. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 15 Within the lifestyle plans, the key worker monitors significant health needs and note the last appointments with the relevant professionals such as the dentist and speech therapist. Staff confirmed that the optician had suggested that residents return after two years. Further support with appointments such as attending Bristol Royal Infirmary Eye Hospital is given. The deputy confirmed that all residents have received their flu jobs, however, not all care workers were able to obtain it due to the shortages. There is a specific epilepsy folder with details of those residents who experience seizures. This gives clear guidelines and information to staff to ensure that the residents are safe. The medication system was inspected. Each resident has a cardex with their photo and profile; medication history; interactions; side effects; emergency contact; allergies and other relevant information. The deputy introduced a checklist, which has ensured that all medications are administered at the correct intervals. All Medication Administration Record sheets were completed. Staff undertake an in-house training day, which is followed by a competency test, then depending upon the results a number of observations are carried out. After this period, staff have to achieve full marks on another competency test. It is recommended that Bristol North PCT continue with their 6 monthly technical checks. The last one was in February 2005. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The complaints procedure is adhered to for residents. Finances need to be accurate at all times. Staff receive adequate training in abuse issues so that they can protect residents at all times. EVIDENCE: A previous requirement regarding residents’ finances has improved, however, a discrepancy was found and the home’s process of recording large withdrawals was not followed for one resident. Therefore the requirement remains. The deputy said that the recommendation of reducing the amount of change on the premises has improved; yet there was still quite a large amount within the residents’ monies. This just makes it more time consuming for staff when trying to balance the figures. The deputy said that staff try to go the bank and change some of the change when they can. There is a complaints folder containing the ‘Making a Complaint’ procedure, which is pictorial and contains photos of all the persons the residents can approach. Previous complaints had been logged in the folder alongside the outcome. The Service User Guide also contains the complaints procedure inclusive of how to contact the CSCI. However, not all Lifestyle Plans contain the guide. All residents must have a copy of the complaints procedure. There are resident’s meetings where residents can air any concerns or complaints. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 17 Residents can present challenging behaviour, so staff are trained in ‘Positive Intervention’ and ‘Managing Challenging Behaviour’ and some newer staffs are due to attend in February 2006. Reports regarding incidents are sent to the CSCI. All staff must be aware of what constitutes abusive behaviour between residents. Training records showed that staff attended Protection of Vulnerable Adults training in July 2004. Newer staff are yet to attend through their induction. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Residents live in a homely environment with bedrooms and shared spaces suiting their needs and lifestyles. Whites must maintain a good level of cleanliness at all times. EVIDENCE: There is a welcome sign on door saying ‘Welcome to Whites, Where Peace, Harmony, lots of tea and radio 1 or 3 combine to make…somewhere nice to live and work’. The requirements from the previous inspection regarding the environment had been met. Now, the residents enjoy two new sofas and a clean back stairwell and new carpet in the back hallway. Whites is quite a large property accommodating 11 residents. There is a gate at the entrance to ensuring the residents’ safety. There is a garden, which needs some attention. A resident from another Freeways home used to tend to the garden but no longer does. There is a vacancy at present to resolve this. The deputy confirmed that the dumped furniture at the rear of the property is due to be removed. A maintenance request has been made. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 19 The porta cabin is in need of attention. It was very cold and staff confirmed that they are less inclined to use the facilities in this weather. There are electric heaters, and the deputy said that if there are turned on prior to using it, it does warm up. It is a cluttered environment with hurdles to overcome to get into the ‘relaxation area’. The deputy said that it was not normally that messy. It is required that the floor space is tidied to lower the risk of accidents. It is also recommended that the space is developed or refurbished. One the first day of the inspection, the kitchen floor and dining areas were found to be unclean. This was told to the staff and by the second day, those areas had been cleaned. The standard of cleanliness must be maintained. There are two dining areas and two lounge areas for the residents’ use. There are photos of the residents throughout the home. Residents were observed accessing all areas of the shared spaces. The seat on one armchair in a lounge was identified to staff as it is badly broken and needs either repairing or replacing. The front stairwell carpet now needs deep cleaning or replacing. Freeways homes share a carpet cleaner which was suggested to be used before another house requests it. Two bedrooms were entered with the specific resident. Both were very personalised with photos and mementos and had the necessary facilities. One resident is responsible for cleaning their bedroom independently and it was found to be extremely clean. It was observed how some residents have keys to their bedrooms. There are three bathrooms and one shower room (one bathroom was not looked in). Most had hand washing facilities (except the shower room) and locks on the door. The downstairs bathroom needs blinds on the windows despite the frosted glass. The shower room’s grouting is black and mouldy. There is no cubicle door or curtain due to certain resident’s mobility. All need a deep clean as discussed with the staff. There are also some bedrooms on the ground floor to increase independence. Pictures on the bathroom doors aid those with limited communication skills. The laundry area has one standard washing machine and one sluice to ensure correct temperatures are reached to wash clothes, and two dryers. Staff told the inspector that they would benefit from another industrial washing machine due to the constant use of the machines. It is advised that staff monitor the usage and decide collectively. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 The home continues to employ a robust recruitment process to protect residents. Staff are well supported by the senior team members and by Freeways to ensure that the residents are well supported. EVIDENCE: Time was spent with support workers, the team leader and the deputy manager, as well as sitting in on the handover meeting. All staff knew their role within the home and spoke positively and confidently regarding their jobs, the residents and the operation of the home. Five staff files and the training records were inspected. The correct documents including two references, confirmation from head office of Enhanced Criminal Records Bureau check and an application form were present. Vacancies have recently been filled. Further, Whites no longer use recruitment agencies to cover short notice shifts. A bank system is in place. The team and residents are benefiting from a more stable core group of staff. However, on both days of the inspection, residents could not partake in planned activities such as shopping and the day service due to staff shortages. This must be rectified, as residents are not being supported as well as they could be. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 21 The training record was not up-to-date but each of the files contained the certificates of training undertaken, such as first aid and manual handling. Despite staff having done first aid training, there are no Appointed Persons within the staff team. It is recommended that there be one member on duty at a time who has completed a 4-day first aid course due to the risk involved with challenging behaviour presented by some of the residents. Three members of staff are presently doing their NVQ level three in care. However, only one member has completed it. The inspector was later informed that four staff (including the manager and deputy) have completed their NVQ Level 4 in care and management. Staff are to be encouraged to complete their qualifications. A member of staff has still not completed their Learning Disabilities Award Framework (LDAF) course since 2002. Staff are expected to finish this within their 6-month induction programme to then progress onto the NVQ course. Good meaningful supervision notes were on file for each of the staff. These occur within the appropriate timescales. Appraisals also took place in July 2005. The deputy confirmed that he had had training prior to undertaking the task, but not with Freeways. During the inspection it was observed how the referral system to the occupational health team provided by Freeways was implemented. It was also noted how extra supervisions can be enabled when a pressing issue arises between staff members. This is good practice. However, it was noted and discussed with the deputy about a complaint from a member of staff 10 months ago and has still not had a response. The issue has remained an issue within supervision sessions. The complaint issue has arisen again this year, which is again causing some conflict. Management must follow the grievance procedure. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 EVIDENCE: The inspector did not meet the manager, but the deputy was present throughout the inspection. He is new in post and keen to improve and develop the home. He has a number of years of experience and has worked for Freeways since 1998. He has completed his NVQ Level 3 in care, and supervision notes indicate that he is progressing very well with his new responsibilities. Whites’ Public Liability insurance and registration certificate were on display and were both correct. The budget breakdown is on display in the office. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 23 It was understood that Freeways are developing a quality assurance system within their Business Strategy. An area manager carries out monthly visits and the CSCI receive these. At present there are no formal arrangements in place to monitor and review the home. This will be a focus of the next inspection. There are three files with policies and procedures. Through discussion with the deputy regarding certain issues (i.e. sickness), it was evident that the policy folders need to be updated; maintained; and dated. It was confirmed that this was a forthcoming task involving spending time at head office. Time must be allocated to this task. Some had been updated such as the ‘Training and Development’ policy. There was no specific Whistle Blowing policy within the policy folders. However, there was a policy named ‘Do the Right Thing’ regarding reporting of malpractice. This needs to be in place so that staff, and residents, are aware of the procedure to ensure good care practice is retained in all circumstances. There is wide-ranging information within the home regarding the residents and operations. Much is in good order and documents are in place complying with legislation. However, there is a need for a generic review of risk assessments and policies. There seemed to be much duplication and through discussion with the deputy, a more organised system would benefit the staff, and therefore the residents. Staff complete the daily records within the lounge area and residents can be involved if they wish. As noted from the communication book, there is a longstanding issue with keeping the cupboard locked. During the inspection, it was open and accessible. This requires to be locked at all times to ensure confidentialities are maintained. Staff have particular house responsibilities such as the health and safety checks, day services, cleaning products and First Aid. The fire logbook was examined and was well maintained. Tests are carried out within the appropriate timescales. Avon Fire Brigade visited the home on 4/2/4 and the last food premises inspection was on 1/2/5. The boiler’s under area needs repairing as it is stuck on with insulating tape and could fall off at any time exposing the mechanics of the boiler. The team leader said that the contractors had been out, some time ago, but never came back. It was suggested that they either need chasing up or use another company. Whites DS0000026557.V263715.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Whites Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 3 2 X DS0000026557.V263715.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? Yes 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. Standard YA5 YA9 YA17 Regulation 5 (b)(c) Requirement Timescale for action 28/02/06 31/01/06 31/01/06 4. YA23 5. 6. YA24 YA27 7. 8. YA24 YA30 Residents’ terms and conditions and agreements to be updated and understood by the resident. 17(3a) Risk assessments and reactive strategies to be reviewed and updated. 12(1a) a) Residents to receive dietary 13(1b) assessments prior to going on a 16(2I) diet. b) Nutritious meal plans are offered rather than microwave meals. Schedule Keep accurate records of all 4 (8) financial transactions. (Improvement made but requirement remains) (Previous timescale 04/05/05) 23(g) The identified armchair to be repaired or replaced. 23(d) a) Downstairs bathroom to have blinds put up. b) The shower room’s grouting needs replacing. c) All bathrooms need a deep clean. 13(4a,b,c) Porta cabin to be kept free from hazards. 23(2d) Cleanliness and hygiene must be maintained at all times. 31/12/05 31/01/06 31/01/06 31/12/05 31/12/05 Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 26 9. 10. YA30 YA32 23(d) 18(a)(cii) 11. YA33 18(a) 12. 13. YA41 YA42 17 (1)(b) 13 (4) The front stairway’s carpet needs a deep clean or replacing. a) Staff need to complete LDAF training within the stated time frame. b) 50 of staff to complete their NVQ in care. Ensure there are sufficient numbers of staff on duty for residents to continue with their activities. Lifestyle plans need to be kept secure at all times. The boiler’s shell needs securing. 28/02/06 28/02/06 31/01/06 31/12/05 31/01/05 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. 3. 4. 5. 6. 7. 8. 9. 10. Refer to Standard YA1 YA6 YA13 YA19 YA20 YA24 YA35 YA35 YA36 YA40 Good Practice Recommendations Ensure that residents have access to their Service User’s Guide. Key Workers to fulfil their role of completing the monthly reports. Continue to develop day services Staff to receive training in Makaton. Bristol North PCT to continue with the 6 monthly technical checks. Porta cabin is refurbished to be more inviting. An Appointed First Aid Persons to be on duty at any one time. Staff team to receive training in healthy cooking for a large number of residents and staff. Management must follow the grievance procedure and ensure that all complaints from staff are responded to. Policies and procedures to be reviewed, updated and dated. Whites DS0000026557.V263715.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Whites DS0000026557.V263715.R01.S.doc Version 5.0 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. 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!