Care Home: 120 Furber Road

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What the care home does well People are supported in making choices about their lifestyle and are offered opportunities to go to the local community, and take part in varied activities. People are supported in keeping in contact with their relatives and friends. Surveys received from relatives confirmed their satisfaction with the service provided. Staff have a good understanding of peoples needs and treat people with respect What has improved since the last inspection? The home has updated the terms and conditions for two new people. There is written and agreed consent for people being supported with their medication. Repairs have been carried out in a bathroom. Staffing records have improved and staff training has been updated. What the care home could do better: Requirements made: The home must update an individual`s care plan showing how their needs in relation to their mobility are to be met. Both care plans and risk assessments must be updated regarding restrictions in place to help ensure people are being supported safely. The home must risk assess an individual accessing the kitchen on their own to show that their safety is respected whilst their independence is promoted. The home must risk assess the arrangements for people to be supported with their finances to help ensure that they are protected from financial abuse. Recommendations made: Include additional information in peoples` terms and conditions relating to the use of the homes vehicle reflecting a true record of payments to be made. Provide accessible and meaningful information for people to help them understand and be involved in their care planning. Involve the views of others within a multi professional setting regarding restrictions in place for 2 people. Inform the individuals care managers of restrictions in place. CARE HOME ADULTS 18-65 120 Furber Road St George Bristol Bristol BS5 8PT Lead Inspector Sarah Webb Unannounced Inspection 2 January 2008 09:30 nd 120 Furber Road DS0000026631.V351683.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 120 Furber Road DS0000026631.V351683.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. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 120 Furber Road Address St George Bristol Bristol BS5 8PT 0117 9352157 0117 9709305 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Ms Carol Mary Halton Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 3 persons aged 50 years and over with learning disabilities May accommodate up to 5 persons aged 65 years and over with learning disabilities 13th November 2006 Date of last inspection Brief Description of the Service: 120 Furber Road is operated by Aspects and Milestones Care Trust and is registered to provide accommodation and personal care for 5 men and women who have learning difficulties between the ages of 50 to 65 years and over. The property is situated in a quiet residential street in St George, on the outskirts of Bristol and close to the South Gloucestershire boundary. There are local amenities within walking distance, and both Bristol and Bath bus routes are close by. The premises has been extended to add a fifth bedroom, and to provide en suite facilities to three bedrooms. There are garden areas to both the front and back of the property. The home is wheelchair accessible. The fees for the home are currently between £1207-12 to £1458.71 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection with the focus on reviewing the progress of the requirements and recommendations from the unannounced visit in November 2006 and in assessing the key standards of the National Minimum Standards. The home has been sending information about events affecting the well being of the people who use the service and monthly reports that monitor the management of the home. The inspection methods used included record checks, case tracking, a tour of the home and discussion with the manager. Staff interaction was also seen during the visit and an individual was spoken with during a mid day meal to help get their views of the service. A completed Annual Quality Assurance Assessment (AQAA) was received before this visit and the information provided also helped with the inspection process. 4 surveys were received from relatives; their comments have been included. The visit took place over one day and feedback was given to the manager during and at the end of the visit. What the service does well: What has improved since the last inspection? What they could do better: 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 6 Requirements made: The home must update an individual’s care plan showing how their needs in relation to their mobility are to be met. Both care plans and risk assessments must be updated regarding restrictions in place to help ensure people are being supported safely. The home must risk assess an individual accessing the kitchen on their own to show that their safety is respected whilst their independence is promoted. The home must risk assess the arrangements for people to be supported with their finances to help ensure that they are protected from financial abuse. Recommendations made: Include additional information in peoples’ terms and conditions relating to the use of the homes vehicle reflecting a true record of payments to be made. Provide accessible and meaningful information for people to help them understand and be involved in their care planning. Involve the views of others within a multi professional setting regarding restrictions in place for 2 people. Inform the individuals care managers of restrictions in place. 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. 120 Furber Road DS0000026631.V351683.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 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements for people coming into the home make sure their needs are assessed and met. People have written information about the terms and conditions of their placement; however people would benefit from more information included reflecting the true cost of any extra payments. EVIDENCE: There have been no people admitted to the home since the last inspection Care files seen showed that people had been fully assessed and their care needs are being reviewed on a regular basis. The home keeps copies, in peoples care files, of a pictorial service user guide, statement of purpose and the terms and conditions of their placement. A requirement for people’s terms and conditions to be updated has been met. This includes the use of the house vehicle and extras including chiropody, hydrotherapy, and holidays. However it would be good practice to also include the cost of the use of the vehicle as this is shared among the people living at the home. All 4 surveys received from relatives said the home ‘always’ meets the different needs of their relatives. A comment made stated that ‘They have turned our relative into a happy, and relaxed person.’ 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some peoples care plans and risk assessments must be updated and in some cases with the involvement of other professionals involved in their care. People would benefit from accessible information in helping to understand how their needs are being met and in the planning of their care. People are encouraged to make decisions about their daily life. EVIDENCE: 3 care plans seen included comprehensive information about how people should be supported. These included household routines, food choices, and interests. Care files also contained ‘Essential Lifestyle Plans’ showing what is important in peoples lives and their likes and dislikes. A requirement has been partially met to update two peoples care plans in order that appropriate and relevant information is available for staff to meet their assessed needs. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 10 Since the last inspection several environmental restrictions has been put in place for them and this is not reflected in their care plan and risk assessments. The Mental Capacity Act (MCA) 2005 that came into force in October 2007 is designed to protect people who lack the ability to make decisions for themselves if they have been assessed as not having ‘capacity’. Staff have responsibilities and duties when taking decisions on other peoples behalf and that decisions are made in the best interests of people. It is evident that these restrictions have been put in place by the home in the best interests of everyone to help ensure their safety; however the home must also involve other professionals in deciding and reviewing on a regular basis if this is appropriate and show that other alternatives have been explored. There have been changes to another person’s care regarding their mobility and it was noted that although staff had been advised by specialist services in how they now support them, their care plan must be updated to reflect new methods of support. It is evident that the manager is aware of the need to provide more accessible information for people, such as pictures, and photographs. This will help people to be more involved and have a better understanding in how they are supported with their care. Peoples’ care is being reviewed through both annual review with social services and monthly reviews managed by keyworkers. Care files identified that keyworkers complete monthly summaries of peoples’ general care, welfare and activities attended. A record is kept of choices people make. For example one record seen showed that an individual had made a choice about the time they had got up, what they had chosen for breakfast and lunch. The overall consensus from returned surveys from families stated that they were happy with the support offered to their relative. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 11 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. People have opportunities to participate in planned activities and access to the local community. Staff support people if they choose to involved with the routines of the home. People are helped in keeping in contact with their families and friends. People benefit from a healthy and nutritious diet EVIDENCE: Two people go to a day service for several days during the week. One of these services is an external day facility that is attended by one person 3 days a week; the other is the Trust’s day service that supports an individual in the community in activities such as swimming. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 12 Staff support the remainder of people in going to the local community and trips to different places. Records showed a breakdown of all daily activities such as trips to garden centres, pantomime, and a steam railway. Two people attend college one day a week whilst another two go to a fortnightly hydrotherapy session. Staff also organise ‘in house’ activities such as gardening and drawing. One person is supported in continuing contact with the church he went to before moving to the home. It was evident that people have been on holidays that have suited their individual needs. One person said they wanted to go on a boat and were taken to the Isle of Wight. The home is now looking at the possibility of them going on a short cruise. Other holidays included staying at ‘Butlins’, and a caravan. There is a house vehicle that has been donated to the home. There are arrangements in place for the maintenance of the vehicle that are shared by everyone, whilst people are charged individually for trips. All 4 surveys received from relatives said the home ‘always’ support people to live the life they choose. Comments also made included ‘Every effort is made to make peoples lives as enjoyable as possible by taking them on holidays and local trips.’ There was evidence that staff encourage people to maintain both contact with their families and with ongoing friendships outside of the home. Care files showed that an individual is supported to visit their friend regularly. All 4 surveys received from relatives said the home ‘always’ helps your relative to keep in touch.’ and that the home is always welcoming. Comments made also said ‘They bring our relative to visit us if we are unable to’ and ‘they always send birthday and Christmas cards from our relative’ 1 survey stated that ‘My visits to my relative is always spontaneous with no notice given to staff’. ‘People are clearly well looked after which gives me peace of mind’. Not all people wish to be involved in the routines of the home. Care files showed that there is 1 person who likes to be involved in carrying out specific tasks such as recycling, and is supervised in making both snacks and a drink on a regular basis. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 13 The home has a fixed 4 to 5 week menu taking into consideration the different seasons. Menus showed that people are offered a choice of nutritious food. Observation of the different times of activities people went to during the day showed that there is flexibility in the times of meals offered. Alternatives meals are prepared showing that people have a choice. Care files showed that there are clear protocols in supporting people with their meals. It was evident during a mid day meal that the majority of people although they require supervision and prompting during meal times, they are encouraged by staff to be independent. A record is kept of food, refrigeration and freezer temperatures. 120 Furber Road DS0000026631.V351683.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 good. This judgement has been made using available evidence including a visit to this service. People are offered personal support in the way they prefer. They are treated with respect and are safeguarded by the home’s medication practices. EVIDENCE: Personal Care statements showed how people want to be supported and care plans included information about peoples’ personal care needs and the way they preferred their needs to be met. Everyone is registered at the same local doctors practice and are supported to access health care services. Health care records showed that people are supported with appointments to the doctor, opticians, consultants and physiotherapists. Daily records also helped to show that their health is monitored. Care files showed that the home works with other specialist professionals in getting advice. The home has notified us of a staff member who hurt their back through assisting an individual to get out of their chair. The needs of this person have been assessed by specialist services and new safe ways of working and supporting them are now taking place. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 15 A hoist is now being used on a regular basis to help ensure both people and staff are kept safe from injury and this was also evidenced through appropriate risk assessments in place. Through observation of staff it was evident that the staff understand their needs well and were supporting this person in a sensitive and caring way. 1 person is also being supported by the both the Learning Disability Team and their doctor regarding their behaviour and this helps staff in providing a consistent approach. The home has also asked for support from a continence advisor. All 4 surveys received from relatives said the home ‘always’ keeps us informed of important issues and always gives the expected care. Comments received stated ‘Any medical problems are immediately acted upon’ and ‘The care our relative is brilliant and I can’t thank the staff enough’. An overall comment said that ‘The staff communicate well with people and treat them with respect.’ The procedures in place for administration, storage and disposal of medication demonstrated that the home practices safe systems. This included seeing documentation showing when medication should be administered and medication profiles included the uses and side effects of each medication. Medication had been signed by administering staff. Stock checks take place on a monthly basis and all medication is signed in and dated. 120 Furber Road DS0000026631.V351683.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. This judgement has been made using available evidence including a visit to this service. People benefit from clear systems for complaints and protection and can be confident that staff will act on concerns. Staff have been trained in abuse helping to ensure people are safeguarded from the risk of harm or abuse. EVIDENCE: The organisation has a comprehensive complaints policy. A copy in an accessible format was found in each persons file, including timescales for responses and contact details of our and advocacy agencies. Relatives surveys received showed that they know how to complain and that the home responds if concerns are raised. One survey also indicated that they had no complaints. There have been 3 written complaints logged since the last inspection. All 3 were from neighbours and recorded both the outcomes and action taken. Due to not all people being able to communicate verbally, staff need to be vigilant in picking up on individuals’ communication. It was evident through observation that staff understand the needs of people well and that staff advocate on their behalf. There are arrangements for staff to be able to feedback any concerns they may have about any individual. Monthly service reviews record any changes or concerns to peoples’ wellbeing and for staff to discuss any concerns that may have been observed regarding the peoples care. The manager said families also advocate for their relatives. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 17 The home has appropriate arrangements for staff to support people with their financial affairs, as they are unable to be responsible for this on their own. Discussion was had with the manager regarding the need to have individual risk assessments setting out controls in place to help ensure that people are protected from financial abuse. The Trust arranges periodic audits of all financial records and procedures. The organisation has safeguarding policies and procedures including whistle blowing processes. Staff can access the local authority policies on the protection of vulnerable adults that are available in the home. All staff have appropriate checks before they start working at the home to help ensure that people are protected. Training records showed that staff have attended training in safeguarding people. 120 Furber Road DS0000026631.V351683.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, 26, 27, 28, 29, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The house is a clean and comfortable environment for people to live in. Communal rooms and facilities are suitable for their purpose and meet the peoples’ needs. EVIDENCE: The home is in keeping with the local community and is located in a quiet residential area in St. George close to shops amenities and bus routes. The property is a bungalow extended to provide accommodation to five people. There is level access into the home and is wheelchair accessible. The house is furnished in a domestic style. The manager said new lounge furniture is on order. People have individual bedrooms; three have en suite facilities providing additional privacy. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 19 There are a further 2 bathrooms that are equipped to help people with mobility impairments and to encourage independence. A requirement has been met to repair a bath panel missing from one of the bathrooms. There is sufficient shared space consisting of a 2 lounge areas, and a conservatory that is used as the dining area. These areas provide suitable space for people to make choices for both quieter areas and more sociable space. Since the last inspection a risk assessment has been carried out for a keypad to be placed outside the kitchen door. An individual is supervised in the kitchen to make snacks and is involved in recycling tasks but is unsafe in being in the kitchen on their own; the keypad is only in operation when there are no staff in this area. As previously recorded in Standard 9 the home must review this restriction on a regular basis involving other professionals in their care. The home must also risk assess this person accessing the kitchen on their own to show that their safety is respected whilst their independence is promoted. Regular maintenance work is carried out by the Trust. This was evidenced through records kept of when staff report issues, and when they are repaired. The manager said that all environmental tasks identified through the business plan had been actioned. However communal areas such as the lounges would benefit from redecoration. There are appropriate arrangements in place to dispose of clinical waste. There are separate laundry facilities. The laundry room has had a recent leak from the roof and the manager has requested repairs. The home has infection control procedures in place and was clean and free from malodours. The home has a garden space at both the back and front of the home and it was evident that a working group within the Trust has carried out maintenance in these areas. 120 Furber Road DS0000026631.V351683.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 good. This judgement has been made using available evidence including a visit to this service. The home is in the process of ensuring staff are qualified and competent in carrying out their duties and responsibilities. An appropriate and robust recruitment procedure is in place. Staff have attended relevant training to help meet peoples’ needs. EVIDENCE: There have been staff changes since the last inspection with 3 staff leaving the home Staff files showed that 3 new staff have been recruited and are in the process of undergoing induction and probationary processes. During the period of recruitment regular bank staff have been used to help provide a consistency in supporting people. The home did not have the recruitment details of the new staff and the manager said that the organisation sends copies to the home to keep once all documentation has been completed. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 21 2 other staffing files were seen and these included appropriate recruitment details showing that references are followed up and appropriate checks made to help ensure that people are protected. All staff files had notification that they had undergone a Criminal Records Bureau check. The AQAA stated that the involvement of people in the recruitment process is an area that the home wants to improve and arrangements are being put in place for an individual to be involved. New staff are given an induction booklet with all relevant information included; this is signed off by the manager once people show they have understood processes and procedures. Training records showed that 1 new staff member had attended values training, abuse awareness, and code of conduct during their induction. A training matrix showed that staff are up to date with statutory training such as manual handling, fire safety, first aid and food hygiene. All staff have also competed training in specific ‘a signing’ technique. The home is working towards all staff qualified through National Vocational Qualification level 3. Currently there are 3 staff are working towards this whilst 1 staff has this qualification. Surveys received relatives stated that they ‘feel the staff have the right skills and experience to look after people properly’ 120 Furber Road DS0000026631.V351683.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 good. This judgement has been made using available evidence including a visit to this service. The home is a safe and well-maintained home. People benefit from their care being kept under review through quality assurance and monitoring systems. The home has arrangements in place to promote and protect the health and safety of people and staff. EVIDENCE: The registered manager has completed the Registered Managers Award and is waiting for this to be verified. She has 10 years experience of working with people with a learning disability. The organisation has quality assurance processes in place to help monitor peoples overall care and the management of the home. A quality audit tool is used using a peer review process. 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 Page 23 Peoples care and the quality of their life and services in the home are reviewed through external facilitators and asking for the views of relatives. The home follows good health and safety monitoring procedures through the organisational health and safety policy; safety audits take place regularly to help ensure peoples safety. Documentation seen included health and safety risk assessments, gas safety, electrical, and servicing of hoists safety inspection certificates. The were in order and continuing service arrangements remain in place. The manager was unable to find the homes fire risk assessment on the day of the visit; a copy was received a few days later and this showed controls in place and that it had been reviewed regularly. 120 Furber Road DS0000026631.V351683.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 3 2 3 3 3 4 x 5 3 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 x 26 3 27 3 28 3 29 3 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 x 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 3 3 3 x 3 x 3 x x 3 x 120 Furber Road DS0000026631.V351683.R01.S.doc Version 5.2 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. Standard YA6 Regulation 15 Requirement Update an individual’s care plan showing how their needs in relation to their mobility are to be met. Update 2 peoples’ care plan regarding restrictions in place. Update 2 peoples risk assessment to include restrictions in place. Risk assess an individual accessing the kitchen on their own. Risk assess the arrangements for people to be supported with their finances. Timescale for action 29/02/08 2. 3. 4. 5. YA6 YA9 YA28 YA23 13(c) 13(c) 13(c) 13(c) 18/02/08 18/02/08 18/02/08 22/02/08 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. 2. 3. Refer to Standard YA5 YA6 YA9 Good Practice Recommendations Include additional information in peoples’ terms and conditions relating to the use of the homes vehicle reflecting a true record of payments to be made. Provide accessible and meaningful information for people to help them understand and be involved in their care planning. Involve the views of others within a multi professional setting regarding restrictions in place for 2 people. Inform the individuals care managers of restrictions in place. DS0000026631.V351683.R01.S.doc Version 5.2 Page 26 120 Furber Road Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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