Care Home: 261 Passage Road

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What the care home does well People who use the service have opportunities to experience community base activities. Members of staff were observed using a friendly and respectful approach to the individuals at the home. People who use the service live in a homely environment that is safe. What has improved since the last inspection? The people who use the service can be assured that a person centred approach to meeting their needs is in place as the staff team have now included further developed their care plans. The people who use the service can be assured that their communication needs are known to the staff team as they are now included in their care plans. The people who use the service are safer as risk assessments, protocols and strategies for people that challenge the service follow Safeguarding Adults guidance. What the care home could do better: The people who use the service would have more complete information if the statement of purpose were reviewed clarify the range of needs that can or cannot be met at the home and the formats symbolised in words and pictures. The people who use the service would be more assured that their health needs were being met if health action plans and medication profiles were developed. The people who use the service would be more assured that they are protected by the staff team if all staff members had completed safeguarding training. The people who use the service would be clearer about the activities the home offers if an activity plan were in place. CARE HOME ADULTS 18-65 261 Passage Road Brentry Bristol BS10 7JA Lead Inspector Jacqueline Sullivan Key Unannounced Inspection 21st October 2008 10:00 261 Passage Road DS0000026544.V368795.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 261 Passage Road DS0000026544.V368795.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. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 261 Passage Road Address Brentry Bristol BS10 7JA 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) 0117 9593223 0117 9699000 www.brandontrust.org The Brandon Trust Mrs Susan Alexandra Massey Care Home 5 Category(ies) of Learning disability (0) registration, with number of places 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to female service users whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 5 Date of last inspection 28th January 2003 Brief Description of the Service: 261 Passage Road is operated by the Brandon Trust to provide residential care for up to five residents all of whom are currently female with a learning disability, aged 40 years and over. The home is registered with the Commission for Social Care Inspection. The manager is Mrs Susan Massey who has a wealth of experience supporting residents with learning disabilities and with the current resident group. She is a qualified Learning Disability nurse as is the Deputy Manager, Joyce Montague. This home blends in well with its neighbouring properties and is close to many local community facilities. There is the shopping area of Crow Lane within walking distance; Henleaze and Westbury village are a short car or bus ride away. The home has access to major bus routes and is a short ride away from the Mall Shopping precinct and the facilities it has to offer. The home has the added benefit of a large wellmaintained garden that is accessible to all residents. The garden provides a safe environment in that it is well fenced off and the home is not on a main road. 261 Passage Road DS0000026544.V368795.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 two star this means the people who use this service experience good quality outcomes. This key inspection was conducted unannounced over one day in October 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined, a tour of the premises was conducted and feedback sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection and notified incidences in the home, (Regulation 37’s). This information was used to plan the inspection visit. Three people live at the home and two people were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the manager, staff and people using the service were gathered through face- to- face discussions. Fees are paid directly into the Trust account and range from £933.00 per week. What the service does well: People who use the service have opportunities to experience community base activities. Members of staff were observed using a friendly and respectful approach to the individuals at the home. People who use the service live in a homely environment that is safe. 261 Passage Road DS0000026544.V368795.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. 261 Passage Road DS0000026544.V368795.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 261 Passage Road DS0000026544.V368795.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 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service would have more information about the home if the statement of purpose were reviewed. People who use the service can be confident they will receive a good service as their individual needs and aspirations are assessed by the staff team. EVIDENCE: The home’s Statement of Purpose briefly describes the aims, objectives and facilities of the home. The Statement of Purpose has been reviewed by the manager since the last inspection. The criteria for admission, the policies and procedures that enable individuals wishing to live at the home, their relatives and funding agencies to make decisions about moving to the home, have now been included. However, it requires further work so that it includes more information about the range of needs that can or cannot be met at the home. It was noted that the current format has not yet been assessed to ensure that those people for whom it’s intended can understand it. The manager said that this is shortly to be completed. Each person has a file that includes the Service User Guide, Statement of Purpose, License Agreement and Terms and Conditions of residency. The 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 9 home’s Service User Guide and License Agreements are symbolised with pictures and words to ensure that individual can understand the documents. Discussions with people that use the service and information in the care files confirmed that introductory visits take place before people move into the home. There are three people living at the home and another person is going to live at the home shortly. The manager showed us the paperwork for this person, which include an initial assessment from the placing authority. The manager stated that she is going to use this information to complete her own assessment. A member of staff and a person living at the home told us that recently one person had completed introductory visits but the people who lived there and the staff team felt that this was not an appropriate placement. One person told us “I didn’t like her.” Members of the staff team told us that it is very important that the current people living at the home like new admissions. One person who uses the service said she felt that the staff listened to her views. 261 Passage Road DS0000026544.V368795.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 and 9. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people that use the service are enabled to have an independent lifestyle as they are supported by the staff team to take risks and make decisions. The people that use the service can be assured that their assessed and changing needs will be met as this information is reflected in their care plans. EVIDENCE: Each person has a Planning for Life File and Intimate Care plans. Personal Plans contain the individuals assessed needs in respect of all aspects of their lives including personal, social, emotional and cognitive care needs. Intimate care plans are then devised from the personal plans. The intimate plans were seen to be up to date. At the last inspection it was noted that the personal plans had not been reviewed in over twelve months. At this inspection it was noted that the plans have now been reviewed. This is done six monthly by the staff team and 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 11 yearly by the placing authority. An independent reviewing officer is used by the home. At the last inspection it was required that a person centred approach to meeting current needs must be adopted when developing personal plans, so that the person is at the centre of their care. It was stated that key elements of choice, rights, inclusion and independence must then be used to meet the person care needs to incorporate their likes, dislikes and preferred routines. This would then ensure that members of staff meet the individuals assessed needs in a consistent and invidividualised way. At this inspection it was noted that for one person this process has been completed and the manager said that they intend to update the care plans for all people who live at the home. This requirement will remain until these plans are in place for all people living at the home. Discussions with the staff team confirmed that they are all working consistently to meet the particular emotional needs of one person who lives at the home who needs additional support at the moment. A keyworker system is in operation at the home and the keyworker role is to support individuals, arrange reviews, meet regularly and they are responsible for coordinating health care appointments. Discussions with the manager, staff members and people living at the home confirmed that reviews include the person’s keyworker, their relatives, outside agencies and advocates. One person who lives in the home has communication needs. At the last inspection it was noted that that a care plan based on the assessed communication needs of this person is not currently in place. At this inspection it was noted that the manager has liaised with a speech therapist and that a communication profile had been completed. The manager has developed the way individuals make decisions by introducing pictures of choices of jewellery and food. The staff on duty gave examples of the way individuals are supported to make decisions about all aspects of their care. These include choice of bathing with or with out staff support, clothes and activities. At the last inspection it was noted that, because of the nature of one person’s challenges, staff needed support and training to manage these situations. While strategies offered guidance to staff on the actions to be taken, strategies and protocols did not follow the Safeguarding Adults guidance. At this inspection the manager said that the person that this refers to is no longer at the home. However it was seen that the strategies and protocols now follow the Safeguarding Adults guidance 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 12 Risk assessments are completed for activities that may involve an element of risk. Risk assessments are based on community access, mobility and personal care. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service would be more confident that they have opportunities to be involved in a range of leisure activities if an activity plan were in place. People who use the service can be confident that the staff team will assist them develop appropriate links with their family and friends. People who use the service can be assured that the staff team will treat them with respect and encourage them to have responsibilities in their daily lives People who use the service benefit from being offered healthy and wellbalanced meals that they choose. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 14 EVIDENCE: Records in the individuals’ care files and in the visitors’ book showed that the people who live there have regular contact with their family and friends. When asked whether they have a lot of visitors, one person who uses the service said, “ I have lots of family. I go out with them a lot.” A staff member said, “She gets loads of visitors. They support her well.” Some people who live there who do not have relatives so the manager has made sure that they have independent advocates. The staff on duty said that staff take individuals to church so that they can meet their spiritual needs. They said it is a very small church and they make people feel very welcome. Discussions with the staff team, people who use the service and recording in the care files confirmed that, with the exception of one person, individuals at the home attend day care provision and are in paid employment. During reviews individuals’ person development is discussed and staff from day care centres are invited to review meetings. The person without day care provision will attend clubs once weekly and will visit shops with the staff at the home, watch TV and read magazines. There are plans to involve this person in another club. The manager said that individuals generally relax during weekends and evenings. At the time of inspection, one person was not at their daycentre as it was closed for a few days. A staff member said that this person would be “glad when she’s back at the daycentre as she really likes it and doesn’t like staying in.” They both went for a walk together during part of the afternoon of inspection. Discussions with the staff team showed that activities in the home took place but they were adhoc. A staff member said that people who live there do so much during the day they like to relax at evenings and weekends. It is recommended that there is a plan of activities in place for the people who live there so that people know what is on offer at the home. Discussions with the people who live at the home and members of the staff team confirmed that regular holidays take place. They use a particular hotel in Blackpool, which the staff team said was “Fantastic”. One person who lives at the home said,” I like Blackpool. I like to go for walks with the staff.” We looked at the menus and saw that people who use the service have well balanced nutritious meals. We were showed pictures of food choices that allow 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 15 people who are not verbal to pick their food. A staff member said that one person “comes shopping in her wheelchair as she likes to look around”. One person who uses the service said” I like the food. I like chicken. Evidence in the regular meetings for people who live at the home showed that food choices are discussed. A record of fridge and freezer temperatures is also maintained. The manager confirmed that there is an expectation that individuals participate in household chores with support from the staff. There is an expectation that they tidy their bedroom, which is done weekly with their keyworker. One person said” I do the polishing in my room and lay the table.” 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 16 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that use the service are protected as their health needs are mostly appropriately met by the staff team. They can be confident that they will receive support in a way that they choose. However they would be more assured that the staff team are working consistently to meet their health needs if health action plans were in place. EVIDENCE: Discussions with the staff team and evidence in the care files confirmed that people who use the service are registered with a local GP and staff accompany individual on health car e appointments. One person is a diet controlled diabetic Records of multiagency visits are kept and show that individuals visit the dentist, optician and chiropodist. The records also show that staff monitor individuals health care needs and where necessary referrals are sought for specialist support. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 17 Protocols were seen to be in place for “When Required” medications and list the triggers and behaviours exhibited which inform staff on administering the medication. It was seen that the home uses monitored dosage system is used to administer medications and the records cross-referenced with the medications held within the system. A record of medications no longer required at the home is maintained which the pharmacist signs to indicate receipt of the medication for disposal. A pharmacist report was seen dated October 2008 that confirmed that the medications systems are well run. At the last inspection it was required that the medication profiles specify the purpose of the medication, the side effects and homely remedies not compatible are not currently in place. At this inspection this was seen to have been met. At the last inspection it was stated that the Medication profiles must form part of the individuals Health Action Plan. At this inspection it was noted that health action plans were not available for all the people that live at the home. The care files showed that all the information to make these plan is available but it had not been organised into one plan. A recommendation has been made that health action plans are in place for all the people who use the service. Homely remedies are administered when needed from a stock supply and medications administered are recorded separately. At the last inspection it was required that the records of paracetamol did not cross-reference with the balances held. At this inspection this was seen to balance. Training records confirmed that medication training is provided for staff that administer medication. One person who uses the homes stated that the staff team ask her about the care she would like to have. For example she likes staff to assist her wash her hair. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 18 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people that use the service can be assured that the staff team listens to their views. The people that use the service can be assured that the staff team will protect them from abuse. EVIDENCE: Discussions with the manager, the staff team and recording in the care files showed that the manager has been very proactive in protecting and supporting one person who lives at the home that needs extra support at the moment. This has meant working closely with the CDLT (Community earning disability team), Physiatrists, psychologists and the safe guarding adult’s team. Appropriate referrals have been seen to be made. The manager has identified specialist staff training to further support and protect this person. Whilst recognising the benefits of this training it was also noted that POVA training had not been completed for all the staff team. The manager was aware of this need and a recommendation has been made about this. The Complaints procedure is in an accessible format and is displayed in the kitchen. We looked at the complaints book and noted that three complaints have been made since the last inspection. The recording showed that the outcome of the complaint and level of peoples’ satisfaction about the complaint were recorded. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 19 House meetings are also used to discuss individuals concerns about group living. When we asked the people who use the service if they felt they could complain to the staff team if they were unhappy about something, one person said, “I would tell the staff.” Evidence in the complaints book showed that this person had made a complaint and the staff team had resolved it to their satisfaction. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 20 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 and 30.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals live in a comfortable, safe and homely environment that is clean and tidy. EVIDENCE: As noted at the last inspection, the property is located within a residential setting and its appearance blends well with the local environment. It was adapted to provide residential care for five individuals with learning disabilities. It is close to shops, local community facilities, restaurants and bus routes. Arranged over two floors with bedrooms on both floors and communal space on the ground floor. There is level access into the home and a chair lift to the first floor ensures that people with mobility needs can move around the home independently. Bedrooms are single and lockable with a combination of the home’s furniture and personal belongings, which reflect the person lifestyle. One person showed us their room. It was seen to be personalised and comfortable. One person told 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 21 us “I like yellow so my duvet is yellow.” The bedrooms have the appropriate furniture necessary to ensure comfort to meet the individuals’ needs and lifestyles. One person had lots of pictures of their friends and relatives who they talked about with the member of staff that accompanied us. The home has two bathrooms with toilets on each floor. On the first floor there is an assisted bath with hydraulic bath chair. One person told us “I like it because I can have a bath now.” On the ground floor a shower room is available. When we went into the upstairs toilet we saw that continence pads were stored on a shelf. Some of the packets were open. We asked a staff member to store these elsewhere as it is not homely to have these on display and there is also a risk of cross infection. A recommendation has been made about this. The lounge and kitchen are open plan, with a separate dining room. The lounge and dining room has sufficient seating for the group to sit together and socialise or have a meal. Each room was homely and comfortable. The staff team and the people who use the service sat together in the lounge and dining areas. The garden is large and attractive. One person who uses the service said they go out there when it’s not raining. The home has a cat which one person said that they really liked. They were seen stroking and talking to the cat. The laundry is away from the kitchen on the first floor, it has painted walls and vinyl flooring for easy cleaning. Sluicing facilities, washing machine, with sluicing cycle and tumble dryer are in the laundry, the washing machine has a cycle for sluicing. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 22 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 and 36. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people that use the service can be assured that are receiving a good service, as the staff team that support them are competent, experienced, well trained and well supported. EVIDENCE: Six female staff are employed permanently at the home and there is 63 hours staff shortage, as there are two vacancies. Discussions with the manager and staff members confirmed that this shortage did not negatively impact on the people who live at the home. The manager said “We use retired staff when we need them.” The manager said that recruitment files are held at the Trust office. The manager said that there is an expectation that managers check personnel records at the Trust office and an employee’s record checklist of the checks are kept at the home. The manager has checked the references, proof of I.D. and Criminal Records Bureau (CRB) checks for the staff working at the home. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 23 The manager explained that the organisation provides 5 days training per year for each member of staff. The training records showed that these have been completed. Staff training needs are discussed during staff supervision. The staff training records showed that there is regular staff training in place, which is chosen to improve the staff teams knowledge about the needs of the people that they are supporting. Records of training show that since the last inspection members of staff have attended training courses based on empowering people, eating and drinking, dealing with trauma and administration of medication. Members of staff are also encouraged to undertake vocational qualification and three staff have NVQ level 2 and two have level 3. Two staff members have completed the Learning Disabilities Award Framework (LDAF). The member of staff on duty confirmed the arrangements in place for staff to maintain their skills to meet the needs of the people living at the home. It was further stated that the training requested is generally provided. We asked the staff team present at the inspection about staff morale and they said that it was good and they worked well together. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 24 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that use the service can be confident that they are receiving a good service as the home is well run and their views are listened to by the staff team. EVIDENCE: The manager has a current nurse qualification and has completed NVQ level 4 and the Registered Managers Award (RMA), a vocational qualification. She has also completed the NVQ standardisation course, respond training, managing investigations and Pova (Protection of vulnerable adults) The member of staff on duty said that the manager is” very good. You can go to her with any problems.” Another staff member said” She bends over backyards to help you.” 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 25 One person who uses the service said, “I like her”. The manager and this person have known each other for over twelve years and it was evident from their interactions that they are very comfortable with each other. A representative of the Responsible Person visits the home monthly and prepares a report on the conduct of the home, a copy of the was available at the home. Fees are paid directly into the Trust account and range from £933.00 per week. The manager said that she acts as appointee for three people currently living at the home. The manager explained that each person has a bank account and cash is withdrawn to cover daily expenses and its kept in safekeeping at the home. Fire Risk assessments were updated on the 04/08/08. These include checking the fire alarm system, emergency lighting, fire fighting equipment and practices for the staff, which entail fire training and fire drills. Staff training records confirmed that staff training is up to date. An accident book is maintained by the home and since the last inspection and five falls were recorded. The visitors’ book showed that are regular visits form the maintenance department, a competent person to check the gas central heating, chair lift and portable appliances annually. The Trust has introduced a Quality Assurance System that annually audits with the staff team and individuals living at the home, the standards of care. The manager said that once the audit is complete the findings are verified by the external manager and sent to the Trust for analysis and the report of the findings is then returned to the home. The manager said that the home’s annual audit was completed in April 2008. The trust is also assessing the home ability to meet equality and diversity goals. The manager has recently attended training in equalities and is working with her team to look at equality and diversity issues. One issue is that it is all female staff team supporting an all female client group. The manager is ensuring that the people who use the service are happy with this. We asked one person who uses the service and she confirmed that she was happy living in an all female household. 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 26 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 2 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 3 X 3 X X 3 X 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 6 Requirement The registered manager should ensure that the Statement of Purpose is further reviewed to make clear the range of needs that can or cannot be met at the home. The format must be accessible for the people its intended. This is a repeat requirement. Timescale of 30/01/08 not fully met. However there is work in place towards completion. The registered manager should ensure that all people have a person centred approach must be used to develop personal plans. This is a repeat requirement. Timescale of 30/03/08 not fully met. However there is work in place towards completion. Timescale for action 30/12/08 2. YA6 12 (3) 02/03/09 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA23 YA30 YA18 Good Practice Recommendations The registered manager should ensure that all staff members complete safeguarding training. The registered manager should ensure that continence pads are not stored in the toilets. The registered manager should ensure that health action plans are in place for all the people who use the service. The registered manager should ensure that an activity plan is in place. YA14 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 29 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 261 Passage Road DS0000026544.V368795.R01.S.doc Version 5.2 Page 30 - 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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