Care Home: 384-386 Southmead Road

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What the care home does well The home has begun to improve in providing more accessible information for people to help them understand the routines of the home and in making decisions. People are listened to with actions taken based on peoples changing needs and choices. The home works well with other professionals in all aspects of peoples healthcare needs. What has improved since the last inspection? The home has improved in the administration of medication and now keeps a record of appropriate information medication. The home has carried out repairs and redecoration to specific areas of the home helping to provide a homely environment for people to live in. What the care home could do better: The home must provide current information for people who may wish to move there so that they can make an informed decision whether this is the right home for them (outstanding requirement, previous timescale 30/09/07)The home must risk assess the night time arrangements in place for people to help keep them people safe. A current risk assessment involving the use of a key pad also needs to be reviewed to ensure this restriction is appropriate to the needs of people. The home must provide specialist equipment for an individual based on the findings of fire risk assessment. Thr home needs to further investigate the use of pictorial formats to include people in the planning of their care. CARE HOME ADULTS 18-65 384-386 Southmead Road Westbury On Trym Bristol BS10 5LP Lead Inspector Sarah Webb Unannounced Inspection 27 November 2007 09:30 th 384-386 Southmead Road DS0000026555.V351813.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 384-386 Southmead Road DS0000026555.V351813.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. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 384-386 Southmead Road Address Westbury On Trym Bristol BS10 5LP 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 9504987 0117 9699000 www.brandontrust.org The Brandon Trust Cassandra Selina Lea Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person with Dementia, over the age of 65. Date of last inspection Brief Description of the Service: Southmead Road is registered with the Commission for Social Care Inspection to provide accommodation and personal care to seven people with a learning disability aged 18 to 65 with one named person over the age of 65 years. The Brandon Trust operates the home that comprises of two adjourning properties that are situated in a residential area close to Southmead Hospital and local amenities. There is a large private garden to the rear of the property. People are accommodated in single bedrooms. The home has one ground floor room. The home has installed a stair lift and adaptations to the bathroom to assist individuals that have mobility issues and those that are getting older. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced Inspection that took place over one day. Discussion was had with the Manager who helped with the inspection process. Some of the people using the service and several of the care team were met during the visit. The inspection process included viewing records in relation to care and support plans, risk management, the administration of medication, staff training and health and safety processes. Further information was also provided through the homes Annual Quality Assurance Assessment. A tour of the home was undertaken and interaction between staff and people was seen during the visit. Surveys were received by 4 people and with one from a relative. Feedback was generally very positive in the care and support offered to people. As a result of this inspection 3 requirements and 2 recommendations have been made. One of the requirements is outstanding from the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The home must provide current information for people who may wish to move there so that they can make an informed decision whether this is the right home for them (outstanding requirement, previous timescale 30/09/07) 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 6 The home must risk assess the night time arrangements in place for people to help keep them people safe. A current risk assessment involving the use of a key pad also needs to be reviewed to ensure this restriction is appropriate to the needs of people. The home must provide specialist equipment for an individual based on the findings of fire risk assessment. Thr home needs to further investigate the use of pictorial formats to include people in the planning of their care. 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. 384-386 Southmead Road DS0000026555.V351813.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 384-386 Southmead Road DS0000026555.V351813.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, & 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. New people admitted to the home can be confident that the home is able to meet their needs. Although they can visit the home to help them make a choice, the home must develop clear information about the service provided including specialist services. EVIDENCE: The Statement of Purpose and Service User Guide have not been fully updated with current information that reflects the service provided. This was a requirement from the previous random inspection. The manager said she has started the process of including relevant information in both documents so that new people wanting to use the service are suitably informed. Since the last inspection a vacancy has been filled. An assessment of this persons needs had been carried out by their social worker to help the home decide whether they can provide a suitable service. The manager explained how this person was admitted from another home, including frequent visits to Southmead Road before they made a choice to move. The home has met the changing needs of an individual with the help of other specialist services involved in their care. They were spoken with and said that they were very happy with the support from staff. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 9 Four surveys received from people using the service said that they were asked if they wanted to move to Southmead Rd and that they had received enough information about the home before they had moved in so that they could make a decision. 384-386 Southmead Road DS0000026555.V351813.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported in being involved in the planning and review of their care. People are supported in making decisions and taking calculated risks in all aspects of their lifestyle. EVIDENCE: Care plans seen included information on peoples communication needs, the promotion of self help skills, mobility and activities people were involved with. ‘Planning for Life’ folders also included peoples, choices, wishes and preferences and areas of their lifestyle. Care plans looked at were written in a person centred way to help people understand how they are supported with their care. There was also suitable information for staff to follow in helping to meet peoples’ needs. Although the manager has started looking at different ways of communicating with people, further discussion was had about the benefits of a more accessible care planning format such as photographs and pictures to help involve people 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 11 more. The need to improve communication strategies for all people with their preferred methods has also been identified through the returned AQAA. Monthly summary progress notes showed that the peoples’ care is being reviewed regularly by the home; however not everyone’s was up to date and current. Daily records are being kept of peoples general wellbeing and activities participated with helping to monitor any changes to peoples’ needs and the outcome of referrals to specialist services. All bar two peoples care has been formally reviewed by social services. The manager said she is looking at individual ways of communicating with people about the routines of the home. Pictorial house meeting minutes help people to understand and to be involved in making decisions. Recordings of the meetings are planned for helping those people with visual impairments. Individual communication support plans seen help staff to understand how people communication. The home also has agreed processes for communication between peoples’ day placements. Risk management is part of peoples care planning process and risk assessments are completed with people so that they agree with any action to be taken. Risk assessments were detailed and had been reviewed. Three surveys received from people using the service said that they always made decisions about what they do each day. One person said that they usually made decisions daily. All four surveys said that they can do what they want to during the day, evening and weekends. 384-386 Southmead Road DS0000026555.V351813.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, 14, 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 are encouraged to lead full and active lifestyles and are supported by staff to access leisure opportunities in the community. Their rights are respected and they are encouraged to take responsibility in their daily lives. People benefit from contact with their families and friends. People are offered a healthy diet and have input into menu planning and food preparation. EVIDENCE: All but two people are involved in attending different day services and planned activities during the week. Two people also attend college placements during term times. One person was waiting to be taken to their placement and another individual described what they did during the week. An individual manages their own time and makes frequent independent visits to the local community. It was 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 13 evident that they plan their individual lifestyle in going out and about and this was seen during this visit. Peoples’ activities are recorded and these included shopping trips to the local community, hair appointments, pubs, cafes and social clubs. An individual said they enjoyed attending church on a regular basis. People have been supported to make choices about their holidays; one person chose to go on holiday on their own. The manager said this was very successful and helped to empower them. A survey received from a family stated that the home supports people to live the life they choose and that they organise ‘clubs, courses, and other activities’ for their relative. People are helped to keep in touch with their families and friends. Several people have close contact with their relatives and have overnight stays. A survey received from a family was positive in that the home helps their relative to keep in touch with them and that they are kept informed of important issues affecting their relative. The home aims to support people with their independence. People are involved in the routines of the home such as with cleaning their bedroom and putting away their laundry. These are called ‘involvement’ days. Two people attending college are involved in courses to help to live more independently and understanding about living healthily. People have been involved in recent discussion about the homes menus and their food choices. A four week menu has been agreed, but this can be changed if wanted. Records showed that this was the case the previous evening when a change was made. 384-386 Southmead Road DS0000026555.V351813.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. Peoples healthcare needs are clearly identified in care plans. These plans help to support staff with suitable information to meet peoples’ needs. Staff demonstrate a good awareness of these issues, and treat people with respect. People are safe guarded by the home’s medication practices. EVIDENCE: Personal health plans including a health profile showed how people want to be helped. These were individually written in a sensitive way showing that peoples’ privacy and dignity is respected and that they are listened to. People are supported with individual healthcare needs and monthly summaries help to monitor peoples’ health and welfare. The home keeps records of medical appointments attended such as doctor, hospital, and community nurse. Other records show people are supported with regular appointments to chiropodist, and optician. The home has regular contact with the local Community Learning Disability Team and makes referrals to appropriate services such as occupational therapy physiotherapy, and speech and language therapy. The manager has also involved specialist services in supporting individuals with issues of consent and in regular review process in place. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 15 Staff have been trained in supporting people with specific medical needs and receive updates annually by specialist services also involved in their healthcare. All staff have been trained in supporting people with dementia and specialist services have also been involved in supporting the home in this area. The procedures in place for administration, storage and disposal of medication demonstrated that the home practices safe systems. This included seeing documentation and protocols showing when and why medication should be administered meeting a specific requirement; medication profiles included the uses and side effects of each medication. Medication had been signed by administering staff. Stock checks take place on a weekly basis and all medication is signed in and dated. The home keeps a record of all medication that is disposed of. 384-386 Southmead Road DS0000026555.V351813.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 know who to go to if they have a complaint and feel confident that their concerns would be listened to and acted on. Staff have been trained in abuse helping to ensure people are safeguarded from the risk of harm or abuse. EVIDENCE: There have been no recorded complaints since the last visit. There is an organisational complaints policy and procedure that indicates time scales to respond to complaints. All individuals’ files had a copy of this. The manager has also developed a specific format for Southmead Road that she feels is more helpful for those living at the home. It was evident that the manager has an awareness of the need to promote and further develop peoples understanding in expressing concerns and complaints. A survey received from a family stated that they knew how to make a complaint about the care provided by the home and also that the home responded appropriately if they had raised concerns. Discussion with an individual indicated that they are listened to regarding any concerns or complaints and that both house meetings and 1:1 meetings with keyworkers take place regularly to talk about anything. One survey returned from people said that they knew how to make a complaint whilst three said they did not know how to. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 17 However, all four surveys received said they knew who to speak to if they were unhappy. One survey said that would speak to the manager’s ‘boss’ if they were unhappy with the manager. Staff spoken with showed how they knew and understood when people with non verbal communication were unhappy. There are appropriate policies and procedures through The Brandon Trust to help ensure people are kept safe. All staff are given training when first employed in protecting people from abuse. Training records showed that all staff have attended both this and updates. Staff have appropriate checks made through the Criminal Records Bureau to also help to keep people safe people. The home keeps us informed of incidents and safeguarding procedures that have been followed appropriately with actions taken. Care files seen showed that the home has developed behaviour management plans including risk assessments and written proactive strategies in supporting people with differing behaviours. These help to keep people safe and inform staff in how to support people if distressed. There are clear policies and procedures in how to support people with their finances. The home has recently started encouraging people to sign for any financial transactions. A random check was made on two peoples monies kept for safekeeping; balances of these were consistent with records held. 384-386 Southmead Road DS0000026555.V351813.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, 28, 29, & 30 Quality in this outcome area is adequate. 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. An individual is not being provided with specialist equipment to help keep them safe. EVIDENCE: Southmead Road is situated close to shops, public houses, and Southmead Hospital; there is a bus stop on the doorstep. The home is in keeping with the local community and is accessible to the current group of people who live there. A tour of the home showed that 3 requirements have been met. Repairs have been carried out to the second floor bathroom, the stairways and hallways have been redecorated and a loose wire has been secured. Everyone has a single bedroom, which is decorated to reflect individuals’ personal tastes. An individual has been supported within their environment in 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 19 meeting their changing needs. This was detailed through the returned AQAA and it is evident that the home has taken a positive approach in helping to make them comfortable and safe in their environment. In discussion with the individual they said they felt well supported. The fittings and furnishings in bedrooms and communal spaces were comfortable and well looked after. Since the last inspection the office space is now on the second floor instead of the ground floor. The manager is aware that as the home has no call buttons installed in peoples’ bedrooms, and as there are no waking staff, a new risk assessment must be completed taking into consideration the individual needs of the two people on the ground floor. The manager is aware and mindful from previous experiences that peoples’ needs can change and that appropriate action is taken. As at the previous inspection, discussion was had with the manager regarding an internal keypad that controls the opening of the front door. This had originally been installed due to the safety of an individual who no longer lives at the home. The manager said 2 people knew how to use the key pad independently, and another person was in process of being shown, but that other people were unable to. The manager needs to update risk assessment regarding this restriction as to whether this is still appropriate to the current needs of people living at the home. A further recommendation is made for this to be completed. It was noted through the returned AQAA that specialist fire equipment that had been identified through fire risk assessment had not been supplied to an individual. This was followed up with the manager who verified that the home was still waiting for the equipment to be supplied. The home was clean and free from odour. Four surveys received from people using the service said that the home is ‘fresh and clean’. 384-386 Southmead Road DS0000026555.V351813.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): 31, 32, & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a staff team who understand their needs and who receive relevant training to meet their needs. EVIDENCE: Two staff spoken with explained their role and responsibilities, and how the team work together in meeting peoples needs. It was evident that they had a good understanding of how individual people should be supported and gave examples of these. All new staff complete a 2 week Trust induction programme including the Learning Disabilities Award Framework and progress to NVQ level 2 awards. The corporate induction also includes the philosophy of the organisation. Four staff have achieved this while 2 are currently working towards this. Training records showed that staff were up to date with their mandatory training including food hygiene, first aid, and manual handling. Staff training records showed future training booked for 2008 including a National Vocational Qualification unit in medication. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 21 Staff personnel files are kept at the Trust office and a separate inspection to examine these records will be undertaken by an inspector. Four of the surveys received said that the staff always treat them well. Whilst two surveys said that staff always listen and act on what they say, the remainder said staff usually listen. Comments from one survey stated ‘some staff do’ & ‘some staff do not understand’ but went on to state that ‘I’m happy here very happy here, stay here until the day I die.’ 384-386 Southmead Road DS0000026555.V351813.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. People benefit from a well run home. There are processes in place to monitor the management of the home with peoples views listened to. The home monitors peoples health, safety and welfare to help ensure people are safe. EVIDENCE: The registered manager Ms Lea is experienced in the care of people with a learning disability. She is currently in the process of completing the Registered managers Award and a National Vocational Assessors Award. It is evident that the manager has made information for staff more accessible and easier to find. Staff spoken with said they are happy with the management of the home and find Ms Lea very approachable. Staff meetings are held on a regular basis to help inform staff and to discuss relevant issues in the care of people. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 23 Regular house meetings are held to access the views of people on the quality of life and services in the home. Surveys returned by people stated that they were happy with the care and support offered. Families are involved in the review of peoples care and support and their views are sought. The home uses an organisational quality assurance tool to monitor all areas of the mangement of the home. This is set out as basic core standards linking to the National Minimum Standards. As recorded in the text of Standard 24 the home has completed a fire risk assessment outlining the hazards and risks and control arrangements in place to help ensure the safety of people. Fire equipment checks were taking place and all staff had attended fire drills and training. Annual Health and Safety Audits are carried out by the Trust and monthly inhouse checks carried out. An external home manager or a senior manager carry out Regulation 26 visits on a monthly basis to monitor the management of the home; copies of these reports are sent to us 384-386 Southmead Road DS0000026555.V351813.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 2 2 3 3 3 4 3 5 x 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 x 27 x 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 3 x 3 x x 3 x 384-386 Southmead Road DS0000026555.V351813.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 YA1 Regulation 4 Requirement Update both the Statement of Purpose and Service User Guide as set out in Standard 1 and provide full information in relation to the full range of people a service is provided to. Send copies of both sent to us. (outstanding requirement, previous timescale 30/09/07) Risk assess the night time arrangements in keeping people safe. Where the Regulatory Reform (fire safety) Order 2005 applies to the care home the registered person must ensure that the requirements of that Order and any regulations made under it are complied with in respect of the care home. Provide specialist fire equipment as identified through fire risk assessment. Timescale for action 28/02/08 2. 3. YA24 YA24 13(4)(c) 23(2)(b) 28/02/08 14/12/08 384-386 Southmead Road DS0000026555.V351813.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 YA24 YA6 Good Practice Recommendations Review through risk assessment the need for the home to continue to use internal key pad. Further investigate the use of pictorial formats to include people in the planning of their care. 384-386 Southmead Road DS0000026555.V351813.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI 384-386 Southmead Road DS0000026555.V351813.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. 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