Care Home: The Thomas More Project - 97 Cromwell 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. 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? People have a copy of the terms and conditions of their accommodation including the amount and method of payment of fees so that they are better informed. The home alone policy has been reviewed to help ensure people are kept safe.Improvements have been made for a person centred approach to be used in individuals` care planning and showing how they want their needs to be met. The basement shower room has been decorated to help provide a more homely environment. A risk assessment of the laundry facilities has been completed to help protect peoples` health and safety. Staff have begun the process of investigating accessible formats to help people understand how they are supported through their care planning. CARE HOME ADULTS 18-65 The Thomas More Project - 97 Cromwell Road St Andrews Bristol BS6 5EX Lead Inspector Sarah Webb Unannounced Inspection 19th February 2008 08:30 The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Thomas More Project - 97 Cromwell Road Address St Andrews Bristol BS6 5EX 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 9423739 F/P 0117 9423739 Thomas More Project Miss Andrea Jackson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 18 - 64 years who have a learning difficulty 20th February 2007 Date of last inspection Brief Description of the Service: Cromwell Road is operated by the Thomas More Project, a charitable organisation, which provides support for people with learning difficulties. The present age range is between 25 yrs to 64 yrs - the home, however, have recently submitted an application to reduce the age range so they can accommodate a new resident who is 20 yrs old. The house itself is residential in style and blends in well with the local community. It is close to many local facilities and amenities. The home has its own transport. The fees range from £414.38 - £553.89 per week. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 a Key Unannounced Inspection with the focus on reviewing the progress of the requirements and recommendations from the unannounced visit on 20th & 21st February 2007 and in assessing the key standards of the National Minimum Standards. The inspection was carried out over a 12 hour period with the manager assisting with the process; people using the service and several of the care team were met and interaction between staff and people was observed. The inspection process included viewing records in relation to admissions, care and support plans, risk management, the administration of medication, and staff training. Further information was also provided through the homes Annual Quality Assurance Assessment (AQAA). Completed surveys were returned by 2 relatives, 1 from a health care professional and 3 staff. Feedback was positive in the care and support offered to people. 4 surveys were returned by people with feedback stating that they felt well supported and were happy living at Cromwell Road. What the service does well: What has improved since the last inspection? People have a copy of the terms and conditions of their accommodation including the amount and method of payment of fees so that they are better informed. The home alone policy has been reviewed to help ensure people are kept safe. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 6 Improvements have been made for a person centred approach to be used in individuals’ care planning and showing how they want their needs to be met. The basement shower room has been decorated to help provide a more homely environment. A risk assessment of the laundry facilities has been completed to help protect peoples’ health and safety. Staff have begun the process of investigating accessible formats to help people understand how they are supported through their care planning. 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. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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. Prospective people are assessed so that the home knows their needs can be met. People have written information about the terms and conditions of their placement EVIDENCE: There have been no new people admitted to the home since the last inspection. The people living at 97 Cromwell Rd are an established group with the majority having lived together for many years. 1 person said that they had lived at the home since it first opened and that they liked living there. People who responded by survey said they were asked if they wanted to move into the home and that they had enough information in making a choice whether this was the right move for them. One person explained that they had moved to the home so that they would be near their family. Care files seen showed that placing authorities had assessed peoples’ needs before moving to the home. Staff spoken to have a good understanding of peoples needs; from speaking to people and from looking at care documentation it was evident that peoples’ needs are being met. When The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 9 peoples needs change the home ask for advice from other professionals in supporting how those changes can be met. A requirement has been met for each person to have a copy of the terms and conditions of their accommodation including the amount and method of payment of fees. Extra payments recorded included use of the house vehicle covering maintenance and road costs incurred. These had been signed by people and those spoken with understood they paid for the use of the homes vehicle. 4 questionnaires were received from people using the service. 2 stated they were asked if they wanted to move to the home, while the other 2 were unable to respond. 3 questionnaires stated that they were given enough information about the home before they moved so that they could decide it was the right place whilst the fourth was unable to respond. A survey received from a family stated that they feel the home ‘always’ meets the needs of their relative, whilst a second survey said they felt the home ‘usually’ meets their relatives’ needs. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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. Staff showed a good understanding of peoples’ needs and care plans had information to help enable staff to support people consistently. Accessible information needs to be further developed so that they are involved in their care planning in a meaningful way. Risk management procedures help to ensure people are supported safely in taking risks but there are some areas that need to be further developed. EVIDENCE: Care files seen included individual profiles, support plans, reviews, daily and monthly reports. Written support plans showed statements of choices made, support required, and how individuals are to be helped. The home has taken on a person centred approach in starting the process of using accessible information to help people understand their care planning and to be part of it The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 11 Support plans were in a symbolised format; the manager said that some people received communication in this same format from a day service they attended. Although 1 person spoken with said that staff had explained the symbols to them originally, they could not remember and did not understand the symbols when asked what they meant. The manager is aware of the need to further investigate other forms of individual communication including the use of photographs to fully involve people in a person centred way. Staff spoken with said there was enough information for them to meet peoples needs but that previous experience was helpful. All 3 surveys received from staff also confirmed they are given up to date information about the needs of the people they support. Peoples’ care is reviewed through separate processes; staff review support plans 6 monthly and provide information to a funding authority 6 monthly. A yearly review is held and people decide who they want to attend such as family members. 1 person chooses to hold their review at their family’s home. People spoken to said that they are listened to and supported and encouraged to make choices about their lifestyle. All 4 questionnaires received from people stated that they could make decisions and do want they wanted to during the day, evenings and weekends. Weekly house meetings take place to help encourage people to speak up and minutes were seen of recent meetings. These are in a symbolised format and are given to people to keep. Risk assessments are incorporated into care planning. Those seen were clear and supported people to take risks as part of an independent lifestyle. However further risk assessments must be developed in some areas; for example the kitchen area is locked at night to promote an individual’s safety. The manager said there are protocols in place for other people to access the area if wanted. Any restrictions must also be recorded as part of their care plan. A requirement has been met to review the home alone policy. This now includes more detail of how staff assess people prior to being left on their own and any risks are included in their care planning. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 benefit from being 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. The menu is varied, and they are able to choose the food they prefer and like. EVIDENCE: People go to varied activities during the week; college courses, day and work placements. 1 person is also supported through an agency to access community facilities. Staff said that people get a good lifestyle with the location of the home suiting peoples’ social needs. This was evidenced through further discussion with people who said they liked going to the pub, dance classes and a social club. 1 person said they were looking for a job The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 13 People have chosen to go on holiday together as a group for the past 2 years. People have been asked if they want to go on separate holidays but that this is their choice. Holidays are chosen through looking at brochures, and this year people have decided to go to Ireland Trips are made when people are on holiday from their placements and records showed that visits to the Isle of Wight and Windsor Castle took place. People spoke with made comments such as “ I like the people living here and the staff”. 1 person said that they make choices about their lifestyle such as the time they come home at night. They also said that they had told the manager that they would like to go out more often at the weekends. A volunteer helps to support people out in the local community during the weekends and to help compliment the 2 other staff on duty. Staff help people in keeping in contact with their families. Staff support people in visiting older relatives during the year who are unable to come to the home. 1 survey received from a family stated that the home “always” helps their relative to keep in touch, whilst another said they “usually” do this. Both surveys said that they are kept up to date with important issues affecting their relative. People are involved in the routines of the home. These are also discussed at house meetings. 1 day is spent at home when people are prompted in the cleaning of their bedroom. Some people help with food preparation such as peeling vegetables. It was evident through observation of individuals openly accessing the kitchen to make drinks that they are encouraged in being independent. Menus showed that people are offered varied and nutritious meals. People spoken with said that they are involved in making choices about the menu and if they did not like some meals then an alternative is offered. Although staff are recording some alternatives meals this is an area that needs to be improved. 1 survey received from a family said that people are “always” supported to live the life they choose, whilst another said this was “usually” the case. Comments made stated that the home “do well to encourage activities.” Staff agreed there are good outcomes for people living at 97 Cromwell Road in that they get a personalised service tailored to their needs. People spoken with identified the differing ways they are supported with both their care and lifestyle. This was also confirmed through daily records. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 supported with both the monitoring and maintaining of their health needs through both local and specialist services. Appropriate action and intervention is taken if peoples’ needs change. People are treated in a respectful manner by staff. People are supported safely with taking medication but there are some areas of recording that need to be improved. EVIDENCE: The majority of people are independent and are given prompts with their hygiene. There is only 1 person who needs additional personal care support. People are registered with a local General Practitioner, dentist, optician and chiropodist and are supported by a number of health care professionals. Staff monitor peoples health and emotional well being. Health records and monthly reports were seen showing appointments attended and referrals made to specialist healthcare professionals. All 4 questionnaires from people stated that the staff treat them well and that they are listened to. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 15 1 said “ I am happy with the standard of care.” I survey received from a family stated that the home “always” gives the support or care to their relative that has been agreed, whilst another survey said that this is “usually” the case. A comment card received from a General Practitioner stated that they are satisfied with the overall care provided to people. Comments made from staff said that the service provides “individualised’ care well and “puts people first.” The procedures for the administration of medication were assessed. The manager has asked the pharmacy to prepare individual written medical sheets describing peoples’ medication. The manager said these are in the process of being completed. Regular medicines are supplied using a monthly blister pack system. One person is able to self-medicate their medicine. The medications held were consistent with the recorded balances. Staff administer and record homely remedies from a stock supply when required. This should also be recorded on the individual’s own record sheet. It is also recommended that a separate record is kept of as required medication for people and staff. All medicines seen were stored securely with homely remedies kept in a separate cabinet. A record is kept of the disposal of unused medicines. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 unhappy, with their concerns listened to and acted on by staff. The home follows appropriate procedures in order to protect people from abuse with staff having received appropriate training. People are supported with managing their finances, but this must be included in their care planning. EVIDENCE: The home has a formal Complaints Policy, an Adult Protection Policy and a Whistle Blowing Policy, which staff can use in confidence to raise any issue or concern they have regarding the service. The complaints procedure is given to people when first admitted to the home and then every year. This has been developed in a picture based understandable format. Signed copies were in peoples care files. There have been no recorded complaints since the last inspection. Three people spoken with said they had no complaints and that staff listen to them if there is anything bothering or worrying them. A staff member said that they know if people are unhappy by their mannerisms and if their usual behaviour changed. All 4 questionnaires received from people stated that they knew who to speak to if they were not happy; 1 person said they would speak to the manager whilst another said they would speak to their key worker. 1 surveys received from a family stated that they knew how to make a complaint and had no reason to raise concerns. Another stated that although The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 17 they had forgot they said they would speak to the manager and that the home “usually” responded appropriately. New staff undergo appropriate checks as part of the recruitment process to help ensure peoples protection. All staff are trained in recognising abuse and the protection of people. Both the manager and staff said that they have asked for advice through a specialist service in supporting an individual with changes to their behaviour. Care files showed that a meeting is planned and strategies are to be discussed in how to support them appropriately. Financial records and 2 peoples monies kept for safekeeping was checked. Monies held were consistent with balances. People are supported with their financial affairs but there was no written information in care plans to show how this is done. The development of written financial and budgeting support in care plans would also help to evidence controls in place in protecting people from financial abuse. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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, & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a clean and homely environment with bedrooms, communal rooms and facilities suitable for their purpose to meet peoples’ needs. EVIDENCE: 97 Cromwell Road is residential in style and blends in well with the local community. It is close to many local facilities, amenities and bus routes. Accommodation is arranged over four floors with shared space on the ground and lower floor and bedrooms on all floors. Bedrooms seen were individually decorated, personalised and presented individual characteristics. 2 bedrooms have been recently redecorated and carpeted. People have keys to their rooms although not all use them. There are protocols in place for staff if needing to enter peoples’ rooms; people sign to agree to a spare key being kept. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 19 There are bathing facilities on each floor. Both top floor bedrooms have en suite facilities. The lounge, stairwells and landings areas have been re carpeted. A requirement has been met for the basement shower room to be decorated. The tiles had been painted presenting a lighter environment. However the manager is aware that this is not an ideal bathroom space. The home has investigated building works to move the shower room to an existing storage space providing an en suite facility. The manager said this would be costly in terms of building works The washing machine is situated in the kitchen and there is a clear for when the machine can be used. A risk assessment of the laundry facilities has been completed to help protect people with their health and safety. The garden area is made use of during the warmer weather; Bar-b-que’s are held and some people enjoy working in the garden. The home was clean and all 4 questionnaires received confirmed that the home was “always fresh and clean”. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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. People benefit from clarity of staff roles and responsibilities and from having a stable staff team who are competent and effective. An appropriate and robust recruitment procedure is in place. The staff are experienced and trained to meet peoples individual needs. EVIDENCE: There are currently 4 care staff employed with a new staff member who is to start work as soon as their CRB is returned. The majority of the staff team have worked at the home for many years. There are also 2 regular casual staff who also support people. Staff spoken with described their role and responsibilities and gave examples of how peoples’ needs are met. They said the team is small, that they work well together and they felt that they provide a flexible service to people. 1 person spoken with said staff “ work very hard and are efficient.” All 3 surveys from families received stated that they felt there are “usually” enough staff to meet the needs of people. 3 staff have achieved a National Vocational Qualification with 1 member of staff working towards this. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 21 3 staff files were seen. These contained recruitment records to show that appropriate checks are made to help ensure peoples safety. Training records showed that staff have attended training including first aid, food hygiene, and health and safety. Other areas of training attended included understanding autism, palliative care, reminiscence, and dementia. Regular staff meetings are planned where communication is passed on and relevant discussion takes place. This was confirmed by staff spoken with, and through surveys also received. 2 surveys said communication between staff “always’ works well, whilst another said that this is “usually’ the case. 3 surveys received by staff also stated that their induction covered everything they needed to know to do the job when first starting work. Also that they are given training relevant to their role and are kept up to date with new ways of working. 1 survey said that they are currently looking at effective communication in supporting people. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 with their views listened to; improvements in feeding back to people and including their views in further developments would help evidence their contribution to the development and planning of the home. There are arrangements in place to promote and protect the health and safety of people and staff. EVIDENCE: The manager has many years of experience in working with people with learning disabilities. She has completed the Registered Managers Award and keeps up to date with relevant training. She said there is to be a focus on training for all staff in the Mental Capacity Act. There are support mechanisms in place for her through an external manager in the organisation who visited the home during the inspection. The returned The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 23 AQAA stated that there is also regular contact with another home manager in the organisation. A support manager who is employed to deputise in the manager’s absence also helps to manage the staff team. There is a low staff turnover in the home that helps in providing a consistent service Peoples’ care is reviewed through both 6 monthly and yearly meetings. Regular house meetings are held to access peoples views on the quality of life and services in the home. Questionairres have been sent out to relatives and are returned to the trustesss of the organisation. A questionairre has also been sent out to people asking for their views and this is in the process of evaluation. The manager is aware that further developments need to be made in feeding back to people the results of the questionairres and how action is to be taken. An annual development plan helps with future changes to be actioned and reviewed. Weekly environmental audits are carried out by staff. Each staff member is responsible for the monitoring of areas of the home such as water temperature and fire checks, rotation of stock and medication. A basement lockable space contains cleaning materials. Stock is checked weekly. A record is kept of accidents and incidents. The manager has completed a fire risk assessment and fire records showed that staff have attended both fire training and drills. However there were no fire safety procedures displayed to be followed in the event of a fire. This was bought to the attention of the manager. Comments made by families in their surveys said that the home did an “excellent job” The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 x 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 2 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 2 x 3 x 2 x x 3 x The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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. 4. 5. Standard YA6 YA6 YA23 YA9 YA20 Regulation 17(1)(a) Sch.3.(1) Sch3 (3)(q) 17(1)(a) 13(4)(c) 13(2) Requirement Further develop individual accessible information. Include in care plans any agreed restriction in relation to the liberty of movement. Include in care plans how people are supported with their finances. Further develop risk assessments to help promote peoples safety. Keep a record of ‘as required’ medication on individual medication administration record. Further develop quality assurance systems to include the views of people using the service. Timescale for action 31/07/08 30/04/08 30/04/08 30/04/08 31/03/08 6. YA39 24(1) 31/08/08 The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.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 Refer to Standard YA17 Good Practice Recommendations Keep a record of alternative meals offered. The Thomas More Project - 97 Cromwell Road DS0000026533.V359996.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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