Care Home: 12 Alfred Street

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What the care home does well The procedures in place for admissions to the home would minimise the potential of people being admitted to the home whose needs cannot be met. Both of the people living in the home have signed residency agreements. People are enabled to make decisions and choices about their lives, and where required staff or other professionals are involved in providing advice. Potential risks to people are identified and steps are taken to minimise those risks while enabling people to continue activities. People lead active lifestyles. People are encouraged to take responsibility for completing chores/tasks around the home.Medication administration is effectively managed and as a result people are not put at unnecessary risks. People that we spoke to stated they would be able to make a complaint about the home if they were unhappy. The home is comfortable, homely, and friendly and meets the needs of the people currently living in the home. People living in the home are protected by the home`s recruitment procedures. Staff training minimises the potential of people`s assessed needs not being able to be met by staff. The acting manager and staff take health and safety seriously, the regular checks completed by the staff minimise the potential risks to people. What has improved since the last inspection? The standard of the accommodation provided continues to improve. The maintenance work completed on 1 person`s bedroom has improved their standard of accommodation to an acceptable standard that they are happy with. Medication administration has improved. The variety and amount of training has increased since the previous inspection was completed. What the care home could do better: Care plans must provide the reader with sufficient detail to enable them to understand the person`s needs/wishes. And, provide the person with a consistently high standard of care that meets those needs/wishes. PCP`s should be reviewed to ensure that the identified goals are still valid. People should then be supported to achieve these goals. All work towards these goals should be recorded. Where people require prompts with their personal care the acting manager must ensure that staff give these prompts regularly as described in the care plans. All of the health assessments should be reviewed to ensure that they are upto-date.The acting manager should ensure that each person has completed a consent form in regards their monies being managed by the home. Personal goals should be identified and all progress recorded to support the home`s quality assurance system. CARE HOME ADULTS 18-65 12 Alfred Street Gloucester Gloucestershire GL1 4DF Lead Inspector Mr Paul Chapman Key Unannounced Inspection 14th August 2008 09:00 12 Alfred Street DS0000067435.V372787.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 12 Alfred Street DS0000067435.V372787.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. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Alfred Street Address Gloucester Gloucestershire GL1 4DF 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) 01452 537102 www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Position vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2007 Brief Description of the Service: The property is a two bedroom terraced house in Gloucester. To the rear of the property is a good-sized garden that is well maintained. The accommodation comprises of a separate lounge and dining room with the kitchen to the rear of the property. On the first floor are two good-sized bedrooms. Currently the service is provided for two men with mild learning and physical disabilities. The home is staffed 24 hours a day, 7 days a week with a minimum of one staff member being on duty at all times. Fees for living in the home are dependant on the assessed needs of a person. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The acting manager completed the AQAA (Annual Quality Assurance Assessment) document for the CSCI. This document highlights what the service This was brought to the attention of the acting manager. This inspection site visit took place on Thursday 14th August 2008 and lasted approximately 4 hours. The acting manager was in attendance throughout the visit. The AQAA was supplied prior to the inspection. We received completed questionnaires from both people living at the home, and 1 member of staff. Time was spent observing the care of people and their interactions with staff. 1 person living at the home spent the morning with us discussing their care. 1 bedroom was seen on this occasion. The care of the person who spent the morning with us was looked at in depth, this included looking at their financial, medication and personal records. 1 member of staff was spoken to about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: The procedures in place for admissions to the home would minimise the potential of people being admitted to the home whose needs cannot be met. Both of the people living in the home have signed residency agreements. People are enabled to make decisions and choices about their lives, and where required staff or other professionals are involved in providing advice. Potential risks to people are identified and steps are taken to minimise those risks while enabling people to continue activities. People lead active lifestyles. People are encouraged to take responsibility for completing chores/tasks around the home. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 6 Medication administration is effectively managed and as a result people are not put at unnecessary risks. People that we spoke to stated they would be able to make a complaint about the home if they were unhappy. The home is comfortable, homely, and friendly and meets the needs of the people currently living in the home. People living in the home are protected by the home’s recruitment procedures. Staff training minimises the potential of people’s assessed needs not being able to be met by staff. The acting manager and staff take health and safety seriously, the regular checks completed by the staff minimise the potential risks to people. What has improved since the last inspection? What they could do better: Care plans must provide the reader with sufficient detail to enable them to understand the person’s needs/wishes. And, provide the person with a consistently high standard of care that meets those needs/wishes. PCP’s should be reviewed to ensure that the identified goals are still valid. People should then be supported to achieve these goals. All work towards these goals should be recorded. Where people require prompts with their personal care the acting manager must ensure that staff give these prompts regularly as described in the care plans. All of the health assessments should be reviewed to ensure that they are upto-date. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 7 The acting manager should ensure that each person has completed a consent form in regards their monies being managed by the home. Personal goals should be identified and all progress recorded to support the home’s quality assurance system. 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. 12 Alfred Street DS0000067435.V372787.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 12 Alfred Street DS0000067435.V372787.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): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an admission policy that minimises the potential risk of people being admitted to the home whose needs cannot be met. EVIDENCE: No new people have been admitted to the home since the previous inspection was completed. The home has a referrals and admission policy. 12 Alfred Street DS0000067435.V372787.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, 8, 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans identify the person’s needs but do not provide sufficient detail to enable the staff to meet the person’s needs consistently. People are empowered to make decisions about their lives and this enables them to lead the service provided in the home. Potential risks to people are minimised through comprehensive assessment. EVIDENCE: 1 gentleman that lives at the home did not wish to speak with us, whilst the other gentleman spent much of the morning with us going through his care file and discussing points of interest. The care file we examined contained a number of care plans, speaking with the person they said, “I have sat with the staff and gone through this”. Examples 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 11 of the plans we saw were signed in agreement by the person and included the following topics: • Communication • Getting up • Shaving • Dressing • Choices • Gardening • Health The care plans we examined were easy to follow and clearly written with the person. The acting manager must be mindful about the level of information contained in care plans. They must contain sufficient information for staff to understand the person’s needs/wishes and provide guidelines that enable staff to meet those needs consistently. In their present form it may be difficult for staff to meet people’s needs consistently. All of the care plans examined had been reviewed in April 2008. Again the person commented that they had been involved in this process. Good practice guidelines state that care plans should always be under review, but should be reviewed at least twice a year. The documents we saw prompted staff to review care plans 3 monthly, but this had not been done. A Person Centred Plan (PCP) was seen in the person’s file. The gentleman we spoke to said that he had written this, and also explained that he felt the goals had not been met. The PCP showed no evidence of the goals being achieved. It becomes a recommendation of this inspection report that the PCP is reviewed and the person is supported to achieve their chosen goals. In the person’s file was a missing persons risk assessment/procedure. It is recommended that the photo on this document is changed as it is quite old and not an accurate reflection of what they look like now. We spoke to the person about making choices. They said “Staff sometimes put me on the right track”. When we asked what sort of things they make decisions about they replied, “I choose what I would like to do, what I want to eat and we are getting a new sofa which I have been helping to choose”. Both of the gentlemen living in the home are expected to complete chores around the home. This may be cooking meals, cleaning, laundry and gardening. The gentleman we spoke with was a keen gardener doing work around the other homes in the organisation. He said “I haven’t had chance to do some of the things around this garden”. We examined the risks assessments completed by the acting manager. There were a good range of assessments covering activities and tasks in, and outside the home. All of the risk assessments we saw had been reviewed in April 2008. 12 Alfred Street DS0000067435.V372787.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People lead active lifestyles that are led by their wishes and staff support them to complete activities where it is required. People living in the home take responsibility for the day-to-day tasks and staff support them to learn new skills and maintain other skills. EVIDENCE: Staff complete activity sheets with each person that plans activities for the coming week. We saw examples of these documents in the kitchen. These showed both people completed a range of activities. Speaking to the gentleman who spent time with us, they confirmed that these activities take place. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 13 When speaking to the person they explained some of the activities they completed regularly and their plans for the coming months. They explained that day-to-day they do some gardening at 1 of the other homes, and work with the organisation’s handy man completing various tasks. They explained that at present (with staff support) they are arranging 2 College courses to start in September. The person said in addition to college they are also trying to get some voluntary work at a local garden nursery. They explained some of their hobbies include making models and they have recently stripped their bicycle down and are in the process of rebuilding it. The other person living in the home did not wish to speak to us during the site visit. Examination of their records showed that they lead an active lifestyle. Observations during the site visit showed staff interacting positively with them, and them being supported to complete tasks. Both people have regular contact with their relatives. The gentleman speaking to us explained that they are in a relationship and that the staff at the home support them with this where it is required. He gave an example of being able to speak to staff when he needs advice. In addition to this other professionals from the Community Learning Disabilities team are providing support. The gentleman that spoke to us said that he visits the local Church from “time to time”. Both people are asked to be involved in completing tasks around the home including their washing, ironing, cooking and cleaning. The home uses the safer food, better business package to minimise potential risks. The person who spoke to us said that they enjoy helping prepare meals with the staff, and “the food is nice and there is plenty of it”. Both people living in the home are involved in shopping for the ingredients for their meals. As well as cooking meals people also have a take-away regularly. The gentleman speaking to us stated, “I like curry, spaghetti Bolognese, Lasagne and a roast”. When asked whether they get these meals regularly they replied, “yes quite often, I am able to choose what I like to eat”. They went on to explain that recently they baked a birthday cake. 12 Alfred Street DS0000067435.V372787.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health needs of people in the home are met by appropriately qualified professionals and the completed assessments enable staff to monitor and meet people’s other needs. Medication procedures and practices minimise potential risks people living in the home. EVIDENCE: Neither of the gentlemen living in the home requires any physical support with maintaining their personal care needs. The support required is in the form of prompts. We examined a care plan for personal care with the gentleman, they explained they thought it was accurate, but agreed more prompting was probably needed to ensure that they completed it. This was brought to the attention of the acting manager. Records seen in the person’s file showed that they had visited other health professionals; notes recorded when these appointments had taken place and the outcome of the appointment. In addition to these documents a health record (identifying previous/current health needs), An “OK health check” 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 15 (record of general health checks) and a hospital assessment (information for health professionals at a hospital admission). The health record was in need of review and had no date to show when it was completed, the Ok health check had been written by the gentleman and reviewed in the past 6 months, but he was unable to remember whether he was involved in writing the hospital assessment. The acting manager should ensure that the health record is reviewed with the gentleman. The previous inspection report made a requirement that the home must inform us when people are admitted to hospital. Since we completed that inspection we have been informed of subsequent hospital admissions. Medication administration was examined. This showed that the current procedures and practices minimise potential risks to the people living in the home. 12 Alfred Street DS0000067435.V372787.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are able to make a complaint if they are unhappy about the service they are receiving and the home’s procedures ensure that the complaints are dealt with effectively. Safeguarding training completed by the staff team minimises potential risks to people living in the home. Records of income and expenditure are detailed and accurate minimising potential risks to people. EVIDENCE: The CSCI have not received any complaints about the service since the previous inspection was completed. The home has received 1 complaint since the previous inspection and records showed this had been managed effectively and completed within 28 days. Speaking with the gentleman about making a complaint he said, “I could make a complaint if I was unhappy”, we asked how they would do this, they replied, “I would speak to the manager if I was unhappy”. We asked whether there was a complaints procedure “Yes there is a complaints procedure, there’s a copy of it on the notice board”. The AQAA completed by the acting manager states that each gentleman would have a safe purchased for their bedrooms. We checked the records of income and expenditure for 1 person; these were seen to be correct. It is recommended that the acting manager completes financial management 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 17 consent document with each person. This document should identify whether each person is happy with the home managing their finances. Staff training records show that they have completed training in safeguarding adults. There was a copy of an Alerter’s guide (safeguarding adults guidance) on the home’s notice board. 12 Alfred Street DS0000067435.V372787.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, 26, 27, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is comfortable, homely, and friendly and meets the needs of the people currently living in the home. EVIDENCE: As part of the site visit all of the communal areas were seen and 1 person showed us their bedroom. Both the kitchen and the bathroom have been re-fitted to a high standard in the past 12 months. It was noted that the shower cubicle appeared to be missing the base trim to finish it. The AQAA completed by the acting manager states that they plan to redecorate the lounge/dining room and new carpets will be fitted. As mentioned earlier in this report a new sofa has been ordered. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 19 We saw one of the bedrooms, it was personalised with the person’s possessions including a TV, DVD player, pictures and models that the person makes. As a result of a Regulation 26 report the CSCI received we completed a random inspection of the home on February 29th 2008. The report highlighted that a window leaked in 1 person’s bedroom and this was causing their personal possessions to go mouldy, and plaster was falling off their ceiling. It had been a requirement of the previous inspection report that this should be addressed, but it had not. On visiting the service we issued the provider with an immediate requirement. At this site visit the person said the window no longer leaked, and visiting the bedroom it had clearly been repaired and redecorated. The person told us that the provider is yet to replace a board game that was damaged as a result of this leak. It is recommended that the person’s damaged board game be replaced. At the previous site visit we noticed there was a crack above the bathroom window, the manager said that this had been reported but not yet addressed. In addition to this the gutting to the rear of the property needs repairing as it is overflowing at the moment. Observations at this site visit showed this had been addressed. On entering the property it was noted there was a lot of rubbish in the front garden. It becomes a recommendation of this inspection report that this is removed. 12 Alfred Street DS0000067435.V372787.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff training minimises the potential of people’s assessed needs not being able to be met by staff. People living in the home are protected by the home’s recruitment procedures. EVIDENCE: There are 3 full-time and 1 part-time member of staff that make up the staff team. Examination of the staffing rota showed that there is normally a minimum of 1 staff member on duty at all times. This increases regularly when the acting manager is on duty. Comments from the gentleman we spoke to included “staff are always about when I need them.” Training records for staff were comprehensive providing certificates for numerous topics/subjects completed by the staff. 1 member of staff has completed an NVQ (National Vocational Qualification) in care. 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 21 We examined recruitment records for 3 of the staff team. Each file contained the appropriate documents as required by these regulations. People living in the home are protected by the home’s recruitment procedures. 12 Alfred Street DS0000067435.V372787.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The acting manager has substantial experience working in this field and this shows in the goals they have identified to achieve in the future which should improve outcomes for people living in the home. Quality assurance is being addressed with people being given the opportunity to give their opinions but further development is required to ensure that all people’s needs are being met. The acting manager and staff take health and safety seriously, the regular checks minimise the potential risks to people. EVIDENCE: The acting manager has been in post for a number of months and was the deputy manager of another of the organisation’s homes before starting at this 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 23 home. They explained that they have worked in this field for a number of years, with the last 5 years specifically supporting people with learning disabilities. They have completed the Registered Manager’s Award (RMA) and will be starting the National Vocational Qualification (NVQ) level 4 in Care in the near future. The manager summarised their style of management as leading by example. The acting manager is in the process of applying for registration with the CSCI. It becomes a requirement of this inspection report that their application is submitted within 3 months of the date of this report. We spoke to 1 member of staff during the site visit and we received 1 completed staff questionnaire. From the information we received it appears that staff are happy working in the home. Speaking to staff about the activities people are regularly involved in confirmed the records we have seen. Observations during the site visits showed friendly and respectful relationships between the staff and people living in the home. Under Regulation 26 of the Care Homes Regulations (2001) where a provider is not in day-to-day charge of the home monthly visits must be completed by someone from outside the home. The organisation employs someone to do this and examination of the reports they complete after each visit show they are thorough, providing detailed feedback to the acting manager and setting targets for them to achieve. Both of the gentlemen living in the home are able to tell staff if they are unhappy about the service they are receiving. The acting manager stated that the organisation’s head office were due to send customer satisfaction questionnaires to families and other professionals. We recommended that records of setting goals with people living in the home, and evidence of them being achieved is also a good way to show the quality if the service being provided. The acting manager has developed a weekly cleaning checklist for staff to follow. This minimises the risk of tasks being forgotten. Each month a member of the staff team has the responsibility for completing a health and safety audit. Records showed that these had been completed regularly and covered areas including: - building and estate, equipment and facilities, kitchen and food hygiene and fire safety. In addition to this monthly audit other audits being completed included medication practice. 12 Alfred Street DS0000067435.V372787.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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 3 X 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15, 12(3) Requirement All care plans must provide the reader with sufficient detail to enable them to understand the person’s needs/wishes. And, provide the person with a consistently high standard of care that meets those needs/wishes. The acting manager must submit an application to the CSCI to become a registered manager. Timescale for action 15/11/08 2. YA37 8, 9 13/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations All the PCP’s should be reviewed to ensure that the identified goals are still valid. People should then be supported to achieve these goals. All work towards these goals should be recorded. Where people require prompts with their personal care the acting manager must ensure that staff give these prompts DS0000067435.V372787.R01.S.doc Version 5.2 Page 26 2. YA18 12 Alfred Street regularly as described in the care plans. 3. 4. YA19 YA23 All of the health assessments should be reviewed to ensure that they are up-to-date. The acting manager should ensure that each person has completed a consent form in regards their monies being managed by the home. Personal goals should be identified and all progress recorded to support the home’s quality assurance system. 5. YA39 12 Alfred Street DS0000067435.V372787.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West 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 12 Alfred Street DS0000067435.V372787.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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