Care Home: 63 Lambrook Road

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What the care home does well People are supported in their chosen lifestyle; they are offered meaningful activities promoting independence and community participation. Staff support people in keeping in contact with their family and friends. People are involved in the running of the home; and can be confident that they will be listened to. People are supported and involved in the process of taking risks safely. The staff are a consistent team who have worked at the home for several years and have a good understanding of their roles and responsibilities. What has improved since the last inspection? Care plans have been reviewed on a regular basis helping to ensure peoples` needs are being met. The service use guide has been developed in a pictorial format helping people to understand how they will be supported in their home.Written agreements show people have agreed to the arrangements for the use of the homes car. A complaints record is maintained detailing action taken and the outcome. Staff have attended regular fire drills. People are encouraged to sign for their own finances. The lounge has been made more homely with suitable furnishings. Work has begun on the garden area to improve its general appearance. What the care home could do better: Provide details in individuals` contracts of a full breakdown of fee and who is responsible for paying this. (unmet from previous inspection ) Update a specific care plan to reflect current practice so that staff support in a consistent way. Review risk assessments to help ensure that risks being taken are monitored and that people are kept safe. Provide equipment for an individual to support them with their care and maintaining their independence. Recommendations: Update staff training in safeguarding to help protect people from the abuse. Show the links between the reviewing processes and peoples support plans. Update the complaints information with the correct details of the Commission for Social Care Inspection. CARE HOME ADULTS 18-65 63 Lambrook Road Fishponds Bristol BS16 2HA Lead Inspector Sarah Webb Unannounced Inspection 5 & 6 February 2008 09:00 th th 63 Lambrook Road DS0000026540.V355861.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 63 Lambrook Road DS0000026540.V355861.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. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Lambrook Road Address Fishponds Bristol BS16 2HA 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 9655912 0117 9709301 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Lawrence Bartlett Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 4 persons aged 40 years and over. May accommodate up to 4 persons with a learning disability who also have a physical disability. 24th April 2007 Date of last inspection Brief Description of the Service: 63 Lambrook Road is a domestic style house in a suburban setting providing accommodation for four people with mild learning difficulties and varying levels of physical disability, operated by Milestones and Aspects Trust. The house was built in the 1960s and has had some adaptations made to the home in order to meet individuals needs. The main Fishponds Road shops are within easy reach by wheelchair or walking. The home has four single rooms and a lounge/dining room. There is both a front and back garden with a patio. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection with the focus on reviewing the progress of the requirements and recommendations from the unannounced visit on 13th September 2007 and in assessing the key standards of the National Minimum Standards. The Manager helped with the inspection process, and all four of the people using the service and several of the care team were met during the visit. As part of the inspection process records were viewed including those in relation to care and support plans, risk management, the administration of medication, and staff training. A completed Annual Quality Assurance Assessment (AQAA) was received before this visit and the information provided also helped with the inspection process. A tour of the home was also undertaken and interaction between staff and people using the service was also seen. Surveys have been received by 4 families, 1, health care professional and 3 staff. Comments made were positive about the care their relatives are offered. Questionnaires received from 2 people living at the home said that they were happy with the support and care offered. What the service does well: What has improved since the last inspection? Care plans have been reviewed on a regular basis helping to ensure peoples’ needs are being met. The service use guide has been developed in a pictorial format helping people to understand how they will be supported in their home. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 6 Written agreements show people have agreed to the arrangements for the use of the homes car. A complaints record is maintained detailing action taken and the outcome. Staff have attended regular fire drills. People are encouraged to sign for their own finances. The lounge has been made more homely with suitable furnishings. Work has begun on the garden area to improve its general appearance. 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. 63 Lambrook Road DS0000026540.V355861.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 63 Lambrook Road DS0000026540.V355861.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): 2, 3, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements for people coming into the home make sure their needs are assessed and met. People have written information about the terms and conditions of their placement; however more information stating the full cost of the service provision and who is paying for this must be included. EVIDENCE: There have been no new people admitted to Lambrook Road since the last inspection. All but one person has lived at the home for a considerable time. The Service User Guide was seen and has met a requirement for this to be made accessible to the people living at the home. Photographs of people showed their involvement in the development of the guide, and comments have been included about their views. Care files seen showed that placing authorities had assessed peoples’ needs before moving to the home. One person explained how they had moved to the home and said that they had visited other homes as well; that this was their choice as it was near their family and church and they knew the area well. They said staff helped them in going to church every week. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 9 All but 1 persons contract had been changed to show the change of financial contributions for the homes car; this was updated during the visit. People spoken with knew that they paid for use of the car and were happy about this. However a requirement is still unmet in showing the full cost of the service provision and who is paying for this. A survey received from 1 family stated that they feel the home ‘always’ meets the needs of their relative, whilst 3 other surveys said they felt the home ‘usually’ meets their relatives’ needs. 63 Lambrook Road DS0000026540.V355861.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 adequate. This judgement has been made using available evidence including a visit to this service. Although people benefit from being involved in making decisions about their lives and in the planning of their care, care plans must reflect current practice in supporting people with their needs. People are supported in making decisions and taking calculated risks in aspects of their lifestyle. EVIDENCE: Three peoples care files were seen were holding contracts, assessments, and records of peoples care planning. Care plans included information about peoples’ personal needs, preferences, mobility, communication, health, life skills and choices. It was evident that people are more involved with their care planning. Individual profiles have been developed with peoples views included in how they wanted to be supported. . 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 11 1 person’s plan was set out with pictures helping them to understand their care and support. A pictorial review of their care also showed their wishes and aspirations. However a staff member spoken with described how they supported an Individual; a change in practice was not reflected in their care plan and must be updated to reflect this. There was some documentation that needs to be signed and dated helping to monitor any changes; it was also evident that the files held old information that could be stored elsewhere. Care plans are reviewed by staff on a monthly basis whilst annual service reviews involve families if wished. The manager is aware of the need to link the reviewing process to support plans ensuring there is a clear record of how people are progressing. It was also stated in the returned AQAA that the home could improve in the recording of more detail to show how people have made decisions From speaking with people examples were given of how they are involved in decision making and have opportunities to speak up at house meetings. People are supported and encouraged to live an independent and fulfilling life and take part in varying activities. This involves helping people to take risks safely in their daily life. Written risk assessments provided information in helping to keep them safe. People are also beginning to be involved in risk taking through a new booklet called “My choices, my risks.” Aspects of risks, what people want and how risks can be taken safely are discussed with people. However there were some risk assessments that need reviewing. 63 Lambrook Road DS0000026540.V355861.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 supported in making choices about their lifestyle and in developing and maintaining their independence. They benefit from opportunities to take part in social, religious and recreational activities in the local community, and in keeping in contact with family and friends. People benefit from meals that offer a nutritious and varied choice. EVIDENCE: People are supported in accessing meaningful activities. Three people attend a day service run by the Disabled Christian Fellowship for between 3 and 4 days per week. It was evident from discussion with all 3 people that they enjoyed it very much. 1 person also enjoys going to college courses. A fourth person attends another day service for 3 days a week. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 13 Staff support people in going to the local community; both records and discussion with people showed they go on regular shopping trips and out for meals. 1 person had a Bristol City football match booked. From speaking them and their key worker it was evident that they have opportunities to visit places of interest to them. They said that the use of the home’s car had made a positive impact on their lifestyle. 2 people are supported to go to church weekly that is an important part of their life. The 2 other people choose to go church every other week. Both people spoken with said they were happy about this arrangement. Staff support people in keeping in contact with their family and friends. An arrangement was made during the visit for a friend to visit that day and another person said that staff take them to see their family regularly. Surveys received from 4 family members said that the home ‘always’ help their relative to keep in touch and that they are ‘usually’ kept up to date with important issues. People are encouraged to be part of the routines of the home. An individual made their own lunchtime snack and said they also make their own breakfast, and set the meal table. They said they were helped to clean their room and do their laundry. Although people plan menus for the week there is a flexibility to make changes and this was evidenced through individual records kept of meals. Menus showed that people have a choice of varied and nutritious food. 2 surveys from families said that their relative ‘usually’ live the life they choose whilst 2 said this was ‘always.’ Comments also made through surveys received included “The staff do a lot with the residents, they show a lot of interest in what the residents want and take them places” . 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are offered personal support in the way they prefer and are safeguarded by the home’s medication practices. Peoples physical health and well being is monitored well met. EVIDENCE: Care plans were seen showing how 2 people are supported with their personal care needs. A recent complaint made by them showed that a bank staff member did not support them as they wanted. This was due to insufficient information for staff to follow in their care plans. 1 of the people spoken with said that since the complaint staff had helped them to provide important information for when bank staff were on duty so that they are supported the way they want. Health Action Plans recorded how people wish to be supported with their health. Records showed that staff work well with other professionals and people are referred to appropriate healthcare specialist if needed. Records also showed that people are supported through differing agencies including the continence advisor, dentist, dietician, physiotherapist and occupational therapist. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 15 Training records showed that staff have attended courses specific to peoples health needs including nutritional needs. It was noted that a staff member is currently investigating attending a training course relating to the skin care. The procedures in place for administration, storage and disposal of medication demonstrated that the home practices safe systems. This included seeing documentation showing when medication should be administered and medication profiles included the uses and side effects of each medication. Medication had been signed by administering staff. Stock checks take place on a weekly basis and all medication is signed in and dated. 2 people self medicate and there are protocols in place to monitor and support them to take their own medication safely. Surveys received from 3 families said that the home ‘always’ gives care to their relative that is agreed whilst 1 survey said ‘usually.’ 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from clear systems for complaints and protection and can be confident that staff will act on concerns. People would benefit from staff receiving updates in safeguarding to help keep them safe. EVIDENCE: The organisation has a comprehensive complaints policy and peoples care files held copies of a pictorial complaints procedure. A recommendation is carried forward to update the complaints information with the correct details of the Commission for Social Care Inspection. The manager said that the monthly service reviews, 1:1 staff support and the house meetings offer the opportunity for people to talk about any concerns and complaints formally. This was seen through records and from talking to people who said they felt confident to talk to staff if unhappy The complaints log was seen and showed that there have been 3 complaints since the last inspection. Two of these were made by two people and have been previously recorded in Standard 18. The complaint was substantiated and the manager has been proactive in taking action and has involved the people in addressing the issue. Both people spoken with said they were satisfied with the outcome of their complaint. The complaints log had recorded action taken and had been signed off. Staff try to resolve any difficulties that may arise quickly to help ensure ongoing good relationships exist between people. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 17 All 4 surveys said they knew how to make a complaint. 2 surveys stated that the home ‘always’ responds appropriately to concerns whilst 2 said ‘usually’ The organisation has safeguarding policies and procedures for staff to follow to help keep people safe. All staff have appropriate checks before they start working at the home to help ensure that people are protected. Training records showed that the majority of staff attended safeguarding training between 4 to 6 years ago. The manager said he is due to attend a refresher; it is recommended that staff are also updated in this area so that they are knowledgeable in relation to current practice and procedures. People are supported individually with managing and handling their finances and are encouraged to sign for any financial transactions made. 1 person manages their finances independently whilst others are encouraged to handle their own monies within a risk management strategy. Financial risk assessments help to keep people safe from financial abuse. People sign for their 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location of the home offers easy access to the local community meeting lifestyle needs of individuals. People benefit from a clean and comfortable environment to live in that is suitable for its purpose and meet the peoples’ needs. Peoples’ needs would be better met through individual equipment being provided. EVIDENCE: 63 Lambrook Road is a detached bungalow arranged into single bedrooms with a large lounge/dining room, kitchen and laundry room. There is a garden space on all sides of the home with accessibility for all people who use wheelchairs when outside. People have access to local amenities, such as shops, pubs, and cafes, with the main Fishponds Rd shops being in easy reach. The home is suitable for people who use wheelchairs being on one level. Improvements have been made to provide a suitable home for the group of people taking into account their mobility needs. The adapted worktops in the 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 19 kitchen and the walk in shower help to encourage people in maintaining their independence. 2 peoples bedrooms have specific equipment to help them with their mobility needs and also in being independent. Redecoration has improved the appearance of the communal hallways, single toilet and shower room. The lounge has improved in its appearance and has space for people to be able to move around. Pictures and furnishings have also helped to present a homely feel. The laundry room contains a domestic washing machine, tumble dryer and wash hand basin. Cleaning supplies are also kept in a locked space in this area. People have been supported by specialist services in accessing appropriate equipment to meet their needs such as getting an adapted keyboard and computer and other sensory aids. An individual has the use of a shower chair. However care files showed they had paid for the chair themselves several years ago. A specialist service spoken with said the manager had explained to the individual that there was a 6 week wait for the chair to be delivered, but if they chose to pay for it themselves it would be delivered earlier. A record needs to be kept to show that they had been given this information and that they had made this decision. The same shower chair is also being used by another person although they have not been assessed by specialist services. Their dignity is not being respected in sharing personal equipment; the manager must refer this person for an individual assessment of their needs and ensure that they are supported individually. The home was clean and there were no malodours. A up to date fire risk assessment has been completed and the manager has involved the fire department in advise about fire evacuation procedures. The garden has been maintained and there are plans to make further improvements so that people can make more use of this area during the summer. 63 Lambrook Road DS0000026540.V355861.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, 34, & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are a consistent and competent team; they have a good understanding of their role and the individual needs of people. People benefit from robust arrangements for the recruitment of staff. Staff have attended relevant training to meet peoples needs. EVIDENCE: There are 6 care staff employed at the home including a regular bank worker. The majority of the team are a long standing team with most of the staff having worked at the home for several years. Staff spoken with showed that they are experienced in working with people with learning disabilities and had a good understanding of what is expected of them and in how they should be supporting people. 5 staff have completed a National Vocational Qualification to help them demonstrate their competence. 2 staffing files observed contained appropriate documentation such as 2 references, proof of staff identity, application, code of conduct, and terms and conditions of employment. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 21 The personnel department keeps copies of police checks and notifies the manager in writing. The manager said he has had verbal confirmation of a new member of staff’s check and is waiting for written notification. 3 surveys received by staff stated relevant checks were made during their recruitment and an induction process covered everything they needed to know to do the job. Training records showed that staff have been trained in first aid, manual handling, and food hygiene. Other training that staff have attended includes food nutrition, working with advocates, and dementia awareness. Future training booked includes advocacy facilitation. The majority of the surveys received from families felt that their relatives were supported with staff who ‘usually’ have the right skills. 63 Lambrook Road DS0000026540.V355861.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 that ensures they are listened to and that is safe and well maintained. There are arrangements in place to promote and protect the health and safety of people and staff. The staff team are motivated to bring about improvements in the quality of peoples life. EVIDENCE: Mr Bartlett has been managing Lambrook Road since June 2006 on a full time basis. He has 17 years experience of relevant experience; he has completed the Registered Managers Award and holds an adult teachers certificate. He also undertakes periodic training in order to update his knowledge. He is currently booked to attend a manual handling trainers course. Surveys received from staff and speaking to staff showed that they have confidence in the manager and are happy with the management of the home. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 23 As stated previously there is a low staff turnover in the home and the consistency of staff presence is important to the wellbeing of the people and in maintaining their care. The organisation has quality assurance processes in place to help monitor peoples overall care and the management of the home. A quality audit tool is used using a peer review process. Staff meetings are held regularly and a team day was held recently. Regular house meetings are held to access the views of people on the quality of life and services in the home. The home follows good health and safety monitoring procedures through the organisational health and safety policy; safety audits take place regularly to help ensure peoples safety. Documents seen included gas safety and electrical inspection certificates. The fire log book, records and maintenance arrangements were up to date. Staff have attended fire safety training. 63 Lambrook Road DS0000026540.V355861.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 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 63 Lambrook Road DS0000026540.V355861.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. 2. 3. Standard YA18 YA9 YA5 Regulation 15 (1) 13 (4) 5 (1) (a) Requirement Update an individual’s personal care plan to reflect current practice. Review risk assessments Contracts must detail a full breakdown of fee and who is responsible for paying this. (Unmet from previous inspection) Provide equipment for an individual to support them with their care and maintaining their independence. Timescale for action 31/03/08 21/04/08 31/03/08 4. YA29 23 (2)(n) 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA23 Good Practice Recommendations To ensure that there are links between the monthly and the annual reviews and the individuals support plan. For the complaint information to updated with the correct details of the Commission for Social Care Inspection in respect of a recent change of address. DS0000026540.V355861.R01.S.doc Version 5.2 Page 26 63 Lambrook Road 3. YA23 Update staff training in safeguarding and protection. 63 Lambrook Road DS0000026540.V355861.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 63 Lambrook Road DS0000026540.V355861.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!