Inspection on 05/08/08 for Blossom Place

This is the latest available inspection report for this service, carried out on 5th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blossom Place 24/05/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Blossom Place 24 Allenby Road West Thamesmead London SE28 0BN Lead Inspector Pauline Lambe Unannounced Inspection 5th August 2008 09:20 Blossom Place DS0000061203.V366145.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 Blossom Place DS0000061203.V366145.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. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blossom Place Address 24 Allenby Road West Thamesmead London SE28 0BN 020 8855 3322 020 8855 8139 blossomplace@btconnect.com www.oliveservices.com The Olive Services Ltd 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) Mrs Olufunke Oluleye Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender Either whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability and dementia - Code MD The maximum number of service users who can be accommodated is: 14 4th June 2007 Date of last inspection Brief Description of the Service: Blossom Place is registered by The Commission for Social Care Inspection to provide personal care for fourteen male or female service users, aged 18 to 65 years of age. The home provides a period of rehabilitation or treatment for people with a mental health disorder. The home is located in a small cul de sac, on a new housing estate, on the borders of Plumstead, Thamesmead and Woolwich. The home is within walking distance of a mainline railway station, local bus routes and shops. The home consists of two, two-storey houses (House A and B) and a detached house, which staff refer to as the activity block. All of the bedrooms are for single occupancy, fully furnished and have an en suite shower and toilet. The activity block includes a computer suite, office space, meeting rooms and a kitchen. All of the service users living in the home have use of the laundry area, which is located between house B and the activity block. There are four parking bays at the front of the home. The fees charged by the home range from £850 - £1000 per week. Service users were responsible for meeting additional costs such as hairdressing, holidays, transport charges and health care not covered by the NHS such as consultation with a psychologist. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 5 Further information about this home can be obtained by requesting a copy of the Statement of Purpose or visiting www.oliveservices.com Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 6 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. The site visit for this unannounced inspection took place over two days. The first visit was on 5th August 2008 and the second on 11th August 2008. The manager was in charge of the service during both visits and with staff and residents assisted with the inspection. Twelve residents were in the home, one person was in hospital and there was one vacancy. The inspection process included a review of information held on the service file, a tour of the premises, a review of records, spending time talking to residents, staff and management and reviewing compliance with previous requirements. The information included in the Annual Quality Assurance Assessment (AQAA) was also reviewed. The service was well managed and residents were satisfied with the care they received, the way staff communicated with them, the meals provided and the environment. Staff were satisfied with the training and support they received to fulfil their roles. Feedback was not received from relatives and no relatives were seen during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 7 Care plans must include details as to how resident’s assessed needs are to be met. Foods with a shelf life must be dated when opened and stored and used in line with the manufacturers guidance. Records for all medicines brought into the home must be kept in such as way as to enable an audit trail to be completed. Two people must sign hand written entries made by staff on administration charts. Staff who commence working in the home prior to receipt of a CRB check must be supervised at all times and the person acting as the supervisor indicated on the staff roster. References received for staff must be verified as genuine where needed. Six good practice recommendations have been included in this report for management to consider. 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. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 8 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 Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 9 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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were admitted to the home based on an assessment of need. EVIDENCE: Prior to admission the funding authority provided information about the prospective resident’s needs. This included information about the person’s physical and mental health needs, risk assessment and care plan. The home manager also completed an assessment to ensure the service was suited to meeting the person’s needs. Residents received written confirmation that based on assessment the service was suited to meeting their needs. A resident spoken with said they had visited the home before admission and that staff helped them to settle into the home. Blossom Place DS0000061203.V366145.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): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments were prepared however both required improvement to ensure they provided adequate guidance for staff. Residents were supported to make decisions about their daily lives. EVIDENCE: Two sets of care records were inspected. Information obtained through assessment was used to prepare care plans. Since the last inspection the manager had introduced a daily ‘individual care plan checklist’. This provided limited information for staff as to how resident’s needs were to be met during each shift. The guidance referred to ‘assist with personal care’, ‘supervise with mobilising’ or ‘prompt with personal care’. These care plans may be adequate when staff on duty know the residents but were not considered adequate for temporary staff or for newly admitted residents. All residents had regular CPA reviews, which were used to amend and update care plans. Daily care records provided little information as to the implementation of care plans. Residents spoken with were satisfied with how care was provided. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 11 Requirement 1 and recommendation 1. The inspector spoke with five residents. People spoken with said they could make decisions about their day-to-day lives. They said they could decide when to get up, what to wear, whether to join in activities, when to have their meal and how to spend their day. Some residents went out alone and others required escorts when out of the home. Staff encouraged residents to take part in the therapy sessions but respected their decision if they did not want to do this. Risk assessments were seen in the care records viewed. These were placed on the front of the person’s folder. Risk assessments were seen in relation to smoking, mobility, challenging behaviour and diabetic care. The guidance for staff on the action needed to reduce the risk was limited on some of the assessments for example one person used a walking stick and the guidance said ‘provide with mobility aid’ and for a second person with mobility problems there was little guidance as to what support staff should provide for the person when mobilising and what action staff should take when the person sat themselves on the floor, which staff said they did occasionally. Recommendation 2. Blossom Place DS0000061203.V366145.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with suitable activities both inside and out of the home. Residents were satisfied with the meals provided. EVIDENCE: A general activity programme was displayed in each house. Staff organised and supported residents to participate in these sessions. Activities provided included beauty therapy, IT sessions, discussion groups, movie nights and coffee mornings. The manager said that individual activity programmes were completed however these were not seen in the two sets of records viewed. Activity records seen showed that sessions took place as planned and residents decided whether to attend or not. A large screen TV was provided in the therapy room and residents enjoyed a film show each week. Most of the residents smoked and liked to spend time in the smoking areas at the back of the houses. Activity records seen for a one month period showed residents had taken part in current affair discussions, movie night, shopping trips, games Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 13 and puzzles, discussion on health and lifestyle and discussions on food provision. Staff recorded the names of the people who took part in the sessions and the names of those who choose not to take part. Residents were provided with the opportunity to enjoy leisure activities outside the home. Staff arranged activities such as pub visits, visits to day centres, local parks, shopping trips and meals out. One resident said how much they had enjoyed a weekend trip out to Kent for a meal. Some residents went out alone and had the ability to access local facilities themselves. Residents were encouraged to maintain contact with their friends and family where possible. There was a pay phone in each of the houses and some of the residents had a personal mobile telephone. No feedback was received from relatives as none were seen during the inspection and the Commission no longer sends surveys to relatives. The service had a carers support group, which met in the home and was co-ordinated by the residents and relatives. The manager said that this worked well and ensured relatives had input into the service. A new cook was in post since the last inspection. The cook planned the menus with the manager and input from residents. Lunch and supper was cooked in the main kitchen and taken to the houses in heated food trolleys. Breakfast and snacks were prepared in the separate houses by support staff or where possible by residents. Menus seen showed that a varied diet was provided. Adequate supplies of fresh, frozen and dried foods were seen in the main kitchen and foods stored appropriately. Each house had adequate supplies of food suitable for breakfast and snacks. In the individual houses it was noted that foods such sauces, spreads and jams were not dated when opened. To ensure foods are used in line with manufacturers guidance foods with a shelf life must be dated when opened. Residents spoken with did not raise any concerns about the meals provided. Requirement 2. Blossom Place DS0000061203.V366145.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): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans need to include details as to how staff will meet resident’s assessed needs. Some improvements were required to medicine management. Residents spoken with were satisfied with how their care needs were met. EVIDENCE: All bedrooms had en-suite shower and toilets, which provided privacy for residents when receiving personal care. As mentioned the care plans seen did not provide adequate information as to how staff should meet residents needs in respect of personal hygiene. The manager and staff said that residents were encouraged to remain and develop independence in relation to personal care with staff providing assistance or prompting as needed. Residents spoken with did not raise concerns as to how their personal needs were met and talked about their level of independence. The majority of the residents had the ability to make their needs known. See requirement 1. The manager said that the service had good working relationships with local mental health services. All residents had care managers and had regular CPA Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 15 reviews. All residents were registered with a local GP and supported to receive other healthcare such as dental and optical when needed. A policy and procedure was provided in relation to medicine management and was last reviewed in October 2007. Satisfactory systems were in place to store, receipt, administer and dispose of medicines. Between the first and second site visit to the service a cupboard to store controlled drugs had been provided and fitted. A medicine fridge was provided but was not currently needed to store medicines and the temperature of the medicine storage room was monitored. Medicines were supplied in dosette boxes or individual containers on a monthly cycle with pre-printed administration charts. Medicines were stored in the administration block and taken to the houses in cool bags for administration. Only staff that have been trained and assessed as competent administered medicines. Receipts were kept for medicines returned to the pharmacy for disposal. None of the residents currently took full responsibility for their medicines. When residents were assessed as being ready to self medicate the process was introduced slowly to ensure compliance and safety and the manager monitored progress. Administration records were inspected for three people. For two people these were correct but for a third person it was not possible to do an audit trail for one medicine as it was not clear when the stock in use had commenced. Hand written entries made by staff on two administration charts seen had not been signed or countersigned by staff. The home kept a supply of homely remedies but not all the items in stock were on the agreed homely remedy list. However the manager said that as the residents had different GPs it was not possible to get an overall agreed homely remedy list therefore no homely remedies were administered to residents without first calling the person’s GP. The manager had started work on implementing medicine profiles for each resident. The need to assess and record staff competency in relation to medicine management annually was discussed and the manager agreed to introduce this. Requirement 3 and recommendation 3. Blossom Place DS0000061203.V366145.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to manage complaints and ensure protection for vulnerable adults. Satisfactory arrangements were in place to manage resident’s money. EVIDENCE: A complaints policy and procedure was provided and a system in place to record complaints made about the service. Records seen showed that two complaints made about the service had been managed appropriately. The service had also received a number of thank you cards and compliments from relatives. Residents spoken with knew the manager by name and said they would talk to her if they had a concern. A policy and procedure was provided in relation to safeguarding adults. This provided satisfactory guidance for staff but did not state clearly that allegations or suspicions of abuse must be reported to the local authority for investigation. This was discussed with the manager who agreed to amend the document. Staff spoken with displayed a good understanding of safeguarding adults and the action they would take if this was reported or suspected. Training records seen showed that since the last inspection some staff had received training on safeguarding adults and a session was planned for additional staff in March 2009. The Commission were informed of one safeguarding concern since the last inspection. This was investigated by management and was not upheld however the findings indicated that the risk assessment for the person needed review. Recommendation 4. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 17 Satisfactory systems were in place to manage resident’s money. Only the manager had access to the money and in her absence left money in the petty cash for residents to use if needed. Records were kept for money received and spent. However to allow residents to develop and maintain their financial management and dignity a number of people were given their pocket money, signed for this but were not expected to provide receipts. The amount of support residents received to manage finances was agreed based on risk assessment and the ability of the resident. Records were checked for three residents, two were accurate but one had a discrepancy. The Commission received information from the manager to show that this had been resolved prior to completion of this report. Blossom Place DS0000061203.V366145.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): Standards 24, 26 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment was pleasant, clean and tidy. Staff had access to hand washing facilities. Residents spoken with did not raise concerns about the environment. EVIDENCE: Communal and private areas of the home seen were clean, tidy and odour free. Furniture and fittings were of a satisfactory standard and residents spoken with did not raise concerns about their environment. Window restrictors and radiator covers were fitted for resident safety. Staff spoken with said that repairs were addressed within acceptable time limits. All of the bedrooms had an en suite shower and toilet and personal toiletries were seen in the rooms viewed. Two bedrooms were viewed with the resident’s permission and both people said they were satisfied with their rooms. Both rooms were pleasant and personal. Residents could have a key Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 19 to their bedrooms based on assessment and all bedrooms had a small fixed safe for people to store valuables and money. Staff had access to protective clothing, liquid soap and hand driers had been fitted in communal toilets and bathrooms. The manager said it was difficult to leave paper towels in these areas as some residents used these to block the toilets and cause flooding in the home. Blossom Place DS0000061203.V366145.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): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were provided and staff had access to training relevant to their role. Some improvements were needed to recruitment procedures. EVIDENCE: From information provided in the AQAA the service had 19 care staff employed, 15 had achieved NVQ 2 and 2 people were working towards this qualification. Overall over 50 of care staff had NVQ 2 qualification. The duty rosters seen for a three-week period showed there were two people on duty at night, one in each house. This meant that staff could not have a break, as there was nobody to relieve them. A third person was on call during the night to assist with emergency situations. Three staff were on duty for the day shifts. One person was allocated to each house and one person assisted on both houses when the need arose. Staff rosters seen supported these staffing level were provided on most days. At the time of this inspection there were 8 residents in house A and 4 in house B. The duty roster included all of the care staff on duty but the times the manager was on duty was not recorded. Staff were seen interacting with residents in a friendly and professional manner. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 21 Residents spoken with said that staff usually listened to what they had to say and provided assistance when needed. Residents knew staff and the manager by name. Recommendation 5. Three staff employment files were inspected. These included the information required by regulation but two references seen had not been verified as genuine. Information in relation to a fourth employee showed that they had commenced work prior to receipt of a CRB check. A POVA first check had been completed however there was no evidence to show that the person was being supervised at all times. Prior to writing this report the manager confirmed that a satisfactory CRB check had been received for the person. Requirement 4. Staff spoken with said they satisfied with the training opportunities provided. Individual training records were inspected for three people. The manager ensured staff had access to relevant training and staff arranged for staff to attend training sessions provided by the local authority and Greenwich College. These showed that all three people had received 3 days training in the last 12 months on topics relevant to their role. For example training was provided on medicine management, safeguarding adults, managing challenging behaviour and the mental capacity act. Blossom Place DS0000061203.V366145.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): Standards 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed overall and attention was given to providing a safe environment for people. A system was in place to review the quality of the service but a development action plan was not prepared. EVIDENCE: The manager was registered with the Commission and had been assessed as having the skills and experience needed to manage this service. The manager has a degree in education, a Post Graduate Diploma in Counselling, is a Registered Mental Health Nurse and has completed the Registered Managers Award. The manager has also undertaken other training relevant to her role. Since the last inspection the manager had delegated areas of responsibility to senior staff to enable her to concentrate on her role. Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 23 The home had developed a quality assurance programme. The programme included auditing an aspect of the service every month over the year. The manager recorded the audit and outcome. Accident records were audited monthly. Copies of audits on medicines and infection control were seen. Feedback was seen from residents in relation to activities and staffing. Resident meetings were held in each house and minutes kept. Staff meetings were held and minutes kept. Regulation 26 visits were undertaken and records of these were seen in the home and sent to the Commission. Issues identified through audits were addressed however there was no overall action plan prepared from the audit findings to show the actions planned to improve the service. This was discussed with the manager who agreed to address this. Recommendation 6. Health and safety records were sampled. The sample included the service records for gas appliances, the nurse call system and fire safety. Fire drills were held and records seen showed that the last one on house A was held on 20/6/08 and on house B on 6/5/08. All service certificates seen were up to date. Monthly health and safety checks were completed and included hot water temperatures, smoke detectors, lighting, radiator covers and window instructors. Since the last inspection COSHH (control of substances hazardous to health) risk assessments had been completed for the items used in the home and were made available to staff. Blossom Place DS0000061203.V366145.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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 Standard YA6 YA17 Regulation 15 13 Requirement Timescale for action 13/10/08 3 YA20 13 4 YA34 19 Care plans must include details as to how resident’s assessed needs are to be met. Foods with a shelf life must be 13/10/08 dated when opened and stored and used in line with the manufacturers guidance. Records for all medicines 13/10/08 brought into the home must be kept in such as way as to enable an audit trail to be completed. Two people must sign hand written entries made by staff on administration charts. Staff who commence working in 13/10/08 the home prior to receipt of a CRB check must be supervised at all times and the person acting as the supervisor indicated on the staff roster. References received for staff must be verified as genuine where needed. Blossom Place DS0000061203.V366145.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 3 4 Refer to Standard YA6 YA9 YA20 YA23 Good Practice Recommendations Daily care records should support the implementation of care plans the provide information about the resident’s lifestyle. Care should be taken to ensure risk assessments include adequate details for staff as to the action needed to reduce the risk to the resident. Staff competency in relation to medicine management should be assessed annually and records made available for inspection. The procedure in relation to safeguarding adults should be amended to show that all allegations and suspicions of abuse are reported to the local authority and the Commission. The duty roster should include the times the manager is in the home. Management should prepare an annual action plan based on audit findings to show what action will be taken to improve the service. 5 6 YA32 YA39 Blossom Place DS0000061203.V366145.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Blossom Place DS0000061203.V366145.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. 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