Care Home: 17 Bowler Road

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What the care home does well The home`s service user`s guide and statement of purpose have been produced in an easy read format to support people with communication difficulties. People`s needs are regularly assessed by staff to ensure that people`s changing needs are addressed. People`s assessed care needs are identified and plans clearly state what action staff should take to meet people`s needs consistently. People are empowered to take decisions about their lives and staff support them appropriately where it is required. Potential risks to people are identified and the assessments completed by staff empower people to take acceptable risks. People living in the home lead active lifestyles supported by the staff team. What has improved since the last inspection? Medication administration ensures that people living in the home are not put at unnecessary risks. The kitchen has been replaced. CARE HOME ADULTS 18-65 17 Bowler Road 17 Bowler Road Northway Tewkesbury Glos GL20 8RZ Lead Inspector Mr Paul Chapman Key Unannounced Inspection 18th June 2008 09:00 17 Bowler Road DS0000016326.V363906.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 17 Bowler Road DS0000016326.V363906.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. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17 Bowler Road Address 17 Bowler Road Northway Tewkesbury Glos GL20 8RZ 01684 297699 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) www.mencap.org.uk Royal Mencap Society To be appointed Care Home 3 Category(ies) of Learning disability (3), Physical disability (3) registration, with number of places 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2007 Brief Description of the Service: 17, Bowler Rd is a detached modern property located on a housing development on the outskirts of Tewkesbury. The home provides care and support for three adults with learning disabilities. The home is owned and maintained by New Era Housing Association and is staffed and run by the Royal Mencap Society. 17 Bowler Road DS0000016326.V363906.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. This inspection took place in June 2008. The deputy manager was present throughout the majority of the site visit and the acting manager was there at other times. The acting manager supplied us with a completed AQAA (Annual Quality Assurance Assessment) before we completed the site visit. Completed surveys were received from the 3 people living at the home, 1 parent, 1 healthcare professional and 3 staff. Time was spent observing the care of people and their interactions with staff. We spoke to 1 person living at the home. The care of 2 people was looked at in depth that included looking at their financial, medication and personal records. 2 staff were interviewed 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 home’s service user’s guide and statement of purpose have been produced in an easy read format to support people with communication difficulties. People’s needs are regularly assessed by staff to ensure that people’s changing needs are addressed. People’s assessed care needs are identified and plans clearly state what action staff should take to meet people’s needs consistently. People are empowered to take decisions about their lives and staff support them appropriately where it is required. Potential risks to people are identified and the assessments completed by staff empower people to take acceptable risks. People living in the home lead active lifestyles supported by the staff team. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 17 Bowler Road DS0000016326.V363906.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 17 Bowler Road DS0000016326.V363906.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, 5 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’s service user’s guide and statement of purpose have been produced in an easy read format to support people with communication difficulties. People’s needs are regularly assessed by staff to ensure that people’s changing needs are addressed. Each person living in the home has a statement of terms and conditions that identifies the landlord’s and care provider’s responsibilities. EVIDENCE: Since the previous inspection was completed the deputy manager has reviewed the home’s Service User’s Guide and the Statement of Purpose. The new documents make good use of the pictures to enable people with communication difficulties to use them. The deputy manager explained that they plan to produce both documents on DVD in the future. There have been no new admissions to the home since the previous inspection was completed. The provider, Mencap has a detailed admission policy for staff to follow when they are admitting someone to the home. Whilst examining the care for 1 person living in the home we saw that there was recently a review of their care needs. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 9 Each person living in the home has an occupancy agreement with New Era Housing (the landlord of the property). In addition to this Mencap produce a document named “a promise to you” which identifies the service Mencap will provide in the home. It was noted that this document needs to be updated to reflect changes to the home’s management. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 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’s assessed care needs are identified and plans clearly state what action staff should take to meet people’s needs consistently. People are empowered to take decisions about their lives and staff support them appropriately where it is required. Potential risks to people are identified and the assessments completed by staff empower people to take acceptable risks. EVIDENCE: Looking at a person’s care file showed that the home use a system of support and action plans. The deputy manager explained that they intended to combine support plans and action plans in the future. All staff are asked to sign support plans to confirm they have read and understand them. The acting manager explained that these documents had been transferred onto DVD format. Unfortunately we were unable to see these as the home’s computer was being repaired. The written documents we saw provided a good level of 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 11 detail about the person’s needs and the steps staff were required to take to meet those needs. Plans seen included: - personal care, mobility, travel, shopping, cooking, laundry, cleaning, living skills, activities, family contact, cultural needs, communication and finance. The person signed all of the plans we saw. People’s cultural needs are assessed and reviewed regularly. One of the people living in the home sat with us and went through their care plans. We spoke to the person about the plans in their file; they said “I worked with the staff on my support plans”. They stated “I’m happy with the care”, “staff are really nice”. Whilst we were completing the site visit we were able to see staff supporting one person to make a decision about what activity they would like to do during the day and what they wanted for lunch. Speaking to the person later in the day they said, “the staff help me to make choices about what I do”. There was further evidence in the person’s file of them being empowered to make choices. Risk assessments have been completed to minimise potential risks to people. We saw completed assessments for risks including bathing, swimming, using the gym, using the kitchen, transferring around the home, behaviour and medication. All of the risk assessments seen provided a good level of detail to enable staff to minimise potential risks. A shortfall identified whilst looking at the risk assessments was that they were only being reviewed annually. It is recommended that these assessments be reviewed at least twice a year. The AQAA completed by the acting manager stated that in the past 12 months 2 people have chaired their own person centred plan (PCP) meetings. They went on to state that they plan to support all people to chair their own PCP meetings in the next 12 months. In addition to these points the acting manager intends to ensure that support plans and risk assessments are produced in a more accessible format. 17 Bowler Road DS0000016326.V363906.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 living in the home lead active lifestyles supported by the staff team. People living in the home are empowered to have choices about what they would like to eat. EVIDENCE: People living in the home lead active lifestyles supported by the staff. Whilst completing the site visit we spoke to 1 person living in the home (the other 2 people were out at day services). The person we talked to said that they regularly attend a local gym with the support of staff. They also spoke about being enabled to use facilities in the local town of Tewkesbury. The person we spoke to said “the staff support me on a day to day basis”. Other records seen showed that all 3 people living in the home were supported to complete various activities both in and outside the home. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 13 A questionnaire completed by 1 of the parents stated, “The home tries very hard to meet my son’s needs, he seems very happy, staff seem to understand him”. Staff help people to maintain relationships with their families, an example of this was that staff were due to drive 1 person down to Devon to see their brother. A good practice recognised by the CSCI is that the 3 people living in the home are able to choose what they would like to eat at individually at each mealtime. This differs from a lot of other homes where people choose meals a week in advance sometimes. Speaking to staff, a person living in the home and checking records showed that regularly 3 different meals are prepared. To enable people to choose meals/food more easily the home has developed picture menus. Staff advise people about healthy eating. The completed AQAA states that people are encouraged to be independent and staff support people with cooking, budgeting, travel and choosing and planning leisure activities. The AQAA states that a planned improvement for the next 12 months is to encourage people to be more independent. 17 Bowler Road DS0000016326.V363906.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. People’s health needs are addressed by appropriately qualified professionals minimising potential risks to their health. Potential risks to people are minimised through the home’s medication procedures. EVIDENCE: Where people require support with their personal care plans are in place to enable staff to support them consistently. The completed AQAA states staff support people to maintain healthy lifestyles by supporting them to attend appointments with other professionals including GPs, dentists and opticians. The records we saw during the site visit supported this. After the previous inspection was completed a CSCI pharmacist completed a site visit. They made a number of recommendations and requirements. This inspection has shown that these issues have now been addressed. Medication 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 15 administration was examined and showed that people living in the home are not put at unnecessary risks. Only appropriately qualified staff are allowed to administer medication, information is made available detailing why medication is required and what side effects may be seen, each person living in the home given written consent to receive their medication. Any homely remedies are agreed by the person’s doctor before they are administered. All medication was seen to be stored securely. The senior support worker must ensure that the medication risk assessment is reviewed as the document seen on this occasion had not been reviewed since May 2007. This becomes a recommendation of this inspection report. 17 Bowler Road DS0000016326.V363906.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 and they are enabled to do this by following the home’s complaints procedure. Records of income and expenditure help to minimise potential risks to people but need to be developed further to ensure unnecessary risks are minimised. EVIDENCE: The home has not received any complaints since the previous inspection was completed; the CSCI has not received any complaints. The home has a complaints procedure and when we spoke to a person in the home. They understood that they could make a complaint if they were unhappy. The senior support worker on duty explained that annually staff sit down with people living in the home and go through the complaints procedure with them. This is a good practice as it helps to enable people living in the home to understand the procedure. A parent that completed a CSCI questionnaire stated, “I have made a complaint before and it was resolved.” Records of income and expenditure were seen to be accurate at the site visit, staff check each person’s money is correct at shift handover. Each person has a financial risk assessment. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 17 Whilst examining the income and expenditure sheets it was noted that the “audit trail” was incomplete as there was no record of a person’s money coming from their bank account. This was brought to the attention of the acting manager and it becomes a recommendation of this report that this is addressed. The majority of the staff team have completed safeguarding adults training in the previous 2 years. The training records showed that the senior support worker and 1 other staff member need to complete the training. This becomes a recommendation of this inspection report. 17 Bowler Road DS0000016326.V363906.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, 28, 29, 30 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. There are some fixtures and fittings around the home that need to be replaced, or cleaned to bring the home up to good standard for the people living there. EVIDENCE: The previous inspection report made 2 requirements relating to the environment of the home. The 1st requirement was for the home’s kitchen to be repaired or replaced. The site visit showed that it has been replaced. The other requirement was that stair carpet should be cleaned or replaced. This has been replaced. A tour of the premises was completed with the acting manager and the senior support worker. The sofa in the lounge is badly worn (with a hole in the arm), and the carpet was dirty and stained. It becomes a requirement of this inspection report that the sofa is replaced and that the carpet is cleaned, or replaced. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 19 We looked at 1 person’s bedroom, the other 2 people living in the home were out so we did not see their rooms. The bedroom we saw had been redecorated but needed finishing (the lampshade was missing). The person who owned the room told us that they chose the colour. Whilst in this bedroom we noticed that the carpet was dirty and needed to be cleaned and that the door did not have a lock on it. It becomes a requirement of this inspection report that the carpet is cleaned and that a door lock is fitted to the door. The senior support worker explained that they have plans to re-develop the garden with the people living in the home. There are 2 bathrooms in the home. The bathroom on the 1st floor was being re-decorated at the time of this site visit. On the ground floor there is an assisted bathroom attached to a person’s bedroom. The home has been adapted to enable a wheel chair user to live at the property. The home has a dedicated laundry room. This has a damp problem that was reported to the landlord in July 2007. The staff on duty explained that it is due to be addressed in August this year. Overall the home provides the 3 people living there with a comfortable and homely environment. At the time of this site visit the home was clean and there were no offensive odours. The completed AQAA highlights the need to re-decorate the ground floor and replace the carpet. The AQAA is inaccurate in that it states that all people have keys to their own rooms. In the case highlighted in this report it is important that the bedroom door can be locked as the door to the bedroom is off the lounge. 17 Bowler Road DS0000016326.V363906.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, 36 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 supported by a competent staff team that are appropriately trained to maintain people’s safety and meet their specialist needs. The home’s recruitment and selection procedure does not put people living in the home at unnecessary risks. EVIDENCE: Currently there is 5 staff employed in the home. The acting manager explained that there is 1 staff vacancy at the moment and they have just recruited to fill this post. The staffing rota showed that there is a minimum of 1 person on duty at anytime, and that where possible there is 2 staff. Discussing staffing with the senior support worker they explained that currently 1 member of staff is suspended. The CSCI were unaware if this, and it should have been reported to us under regulation 37. The senior support worker/acting manager must be mindful of this in the future. All new staff complete LDAF (Learning Disability Award Framework) training as part of their induction. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 21 Training records were examined and showed that the majority of the staff had completed training in health and safety, food hygiene, first aid, moving and handling, safe handling of medication, fire safety, safeguarding vulnerable adults and risk assessment. In addition to this training staff have also completed specialist training dementia, autism and epilepsy. 3 staff have completed NVQ (National Vocational Qualifications) in health and social care, and 2 others are due to start theirs in the near future. The completed AQAA highlights the need for staff to complete their NVQ’s within 18 months. A sample of staff files were seen. All of the files examined contained the documents required by these regulations. As part of this we examined a sample of staff CRB disclosures (Criminal Records Bureau). We explained to the senior support worker that once the CSCI had examined a CRB disclosure they could be destroyed. We also explained that CRB disclosures should be stored together, not in the staff’s individual files. This becomes a recommendation of this inspection report. A record of staff supervision sessions were available to see and showed that people receive supervision regularly. Staff confirmed this. The acting manager explained that they would be completing the staff annual appraisals in October. 17 Bowler Road DS0000016326.V363906.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 home’s management team provide staff with support and guidance to meet the needs of people living in the home. The home’s health and safety procedures minimises potential risks to people living in the home. EVIDENCE: The service has been going through a period of review. We spoke to the acting manager about this and it has been decided that they will apply to become the registered manager of the home. This becomes a requirement of this inspection report. It was noted the home’s insurance certificate displayed in the office was out of date, staff stated that there was a new certificate, it just needed to be put up. The acting manager must ensure that this is done. 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 23 The acting manager is responsible for overseeing 2 Mencap homes and a lot of the day to day management of this home is overseen by the senior support worker. Observations during this site visit showed the senior support worker to be knowledgeable, committed and enthusiastic in their role. Comments made to us during the site visit supported this. Mencap complete an annual service review of the home. The service review highlights shortfalls and set goals to be achieved. The home’s progress towards meeting these goals is then monitored by the area manager responsible for overseeing the home. We saw records that provided evidence of the area manager monitoring the home’s progress towards these goals. The acting manager explained that they intend to send quality assurance questionnaires to parents and other professionals involved with the home. The completed AQAA states that a planned improvement for the next 12 months is more involvement of the people living in the home in the continuous improvement of the service. We looked at a range of records that showed potential risks to health and safety are monitored. These included: • Fridge and freezer temperatures are monitored twice daily. • Portable appliance testing was completed in July 2007. • Fire safety checks are completed regularly by staff and qualified engineers. • Water temperatures are recorded monthly. • Showerheads are de-scaled regularly. • There are risk assessments for legionella and water hygiene. • COSHH sheets are available for cleaning chemicals used in the home. • Incidents and accidents are recorded thoroughly. The points identified above go a long way to minimising potential risks to people living in the home, but a food probe must be purchased to enable food to be tested, and results recorded. This becomes a requirement of this inspection report. 17 Bowler Road DS0000016326.V363906.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 X 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 2 X 3 X X 2 X 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(b) Requirement The sofa in the lounge must be replaced as the present one has a hole in it. The carpet in the lounge is dirty and stained and must be cleaned or replaced. A lock must be fitted to the bedroom door identified in the body of the report. Timescale for action 26/09/08 2. YA24 23(2)(d) 26/09/08 3. YA26 12(4)(a) 22/08/08 4. YA26 23(2)(d) The bedroom carpet highlighted 26/09/08 in the body of the report must be cleaned or replaced. The acting manager must register with the CSCI. This standard was not assessed at this inspection. The timescale for action was 11/04/07. 24/10/08 5. YA37 8(1)(a) 17 Bowler Road DS0000016326.V363906.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA20 YA23 Good Practice Recommendations The medication risk assessments should be reviewed. Financial records kept for people living in the home should be reviewed. Records must include monies withdrawn/or deposited from/to bank accounts. The staff that have not completed safeguarding adults training in the previous 2 years should complete refresher training. CRB disclosures should be securely stored together in 1 folder/file. A food probe should be used to monitor the temperature of the food/meals being prepared in the home. 3. YA23 4. 5. YA34 YA42 17 Bowler Road DS0000016326.V363906.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 17 Bowler Road DS0000016326.V363906.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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