CARE HOME ADULTS 18-65
111 Crescent Road 111 Crescent Road Crumpsall Manchester M8 5SH Lead Inspector
Steve O`Connor Unannounced Inspection 15th June 2007 10:00 111 Crescent Road DS0000021703.V334651.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 111 Crescent Road DS0000021703.V334651.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. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 111 Crescent Road Address 111 Crescent Road Crumpsall Manchester M8 5SH 0161 740 9405 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) Southfields Care Homes Limited T/A The Regard Partnership Limited Care Home 3 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (2) of places 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named service user requires care by reason of learning disability. Should this named individual no longer reside at the home then the registration will revert to 3 places for mental disorder (MD) 4th September 2006 Date of last inspection Brief Description of the Service: The care home provides 24-hour accommodation and support for three people who need support because of their mental health problems. In addition one person has additional learning disabilities. 111 Crescent Road is a detached house situated in the Crumpsall area of Manchester. The house is on a main road with access to public transport and local shops. The house has three large bedrooms, two lounges (one of the lounges is a smoking area), a bathroom and downstairs toilet plus a kitchen / dining room. There is a small room used by staff as an office and a staff sleep-in room. The house has gardens to the front and rear of the property that are accessible by clear pathways. Information provided by the home showed that the fees ranged from £1400 to £1700 per week. Information about the service can be found either at the home or through the main organisation (The Regard Partnership). 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was last inspected in September 2006. This information includes an Annual Quality Assurance Assessment. During the site visit time was spent observing how staff work with people who live at the home and taking to staff on duty. Documents and files relating to people and how the home is run were also seen and a tour of the building was made. The inspection report of September 2006 highlighted a number of areas that the home needed to work on and improve. The home was working towards addressing these issues and had made improvements in those areas. These will be shown through this report. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needed to undertake with the home. What the service does well:
The home has continued to recognise that the people they support have often had little or no control over the choices and decisions that affect their lives. The home offers people the opportunity to become as involved as they wish in domestic household jobs; in the clothes and personal items they buy, in how they wish to spend their time, who to spend it with and the activities they want to do. Quite often people may decide not to take up these chances to be involved but it is the importance of having the choice that gives people a greater feeling of having some control over their lives. An area that the home has continued to work well was in maintaining people’s general health and mental wellbeing. The home supported people to access local general health services such as the G.P. dentist, chiropodists, etc. Several people had experienced specific health problems and the home had made sure that they had got support from specialist healthcare services and had worked with those services to monitor and maintain people’s health. In addition, people had been supported in a consistent and positive way that meant that incidents of emotional ill health had reduced and this had allowed people to take up more opportunities to participate in activities that they value and enjoyed.
111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 6 People living in the home have benefited from being supported by a more consistent and knowledgeable staff team who can communicate well and have a good understanding of peoples’ personal, social and emotional needs. What has improved since the last inspection?
The previous inspection report highlighted a number of areas that the home needed to make improvements. From the evidence seen the management, staff team and organisation have shown that they have worked hard in addressing many of these. They include: Since the last inspection report the care planning system had improved that aimed to be more person centred in recording how people wanted to be supported and be involved more fully in the deciding their own goals and support needs. A ‘Keyworker’ system had been introduced where a named member of staff would work more closely with a person to regularly review the support they received and to raise any concerns or changes in their needs. The care planning system included a process for identifying and recording risks and hazards that people may experience. Examples were seen where the home had worked with specialist healthcare providers to identify risk situations and to develop ways to support people to minimise those risks so enabling them to take part in activities they enjoyed and to make sure that people maintained their emotional health. Examples were seen of how the home had sought and supported people to take part in culturally relevant activities and had also worked with other specialists to develop clear and structured programmes of activities that met the person’s individual needs. Records of these activities and the 1:1 support offered were being maintained. People were encouraged to decide what they wanted for meals and it was seen that different choices were offered at all times. The meals provided were based on a persons likes and dislikes and their health needs. Eating and drinking guidance and guidelines had been developed to support a person at mealtimes. The home had developed and introduced a new set of guidelines for the support of peoples’ personal finances and monies. This set out the procedures for staff to follow and the auditing system. Finance records were checked and found to be accurate and to be following the set procedures. The training schedule provided by the company that manages the home and other training providers had improved and included dates for an Induction programme, mental health, and care planning training. The Induction training programme was based on the Skills for Care Induction modules. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 7 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. 111 Crescent Road DS0000021703.V334651.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 111 Crescent Road DS0000021703.V334651.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at the home had their needs assessed prior to admission to the home. EVIDENCE: No new people had been admitted to the home since the last inspection and each person had a pre-admission Care Management or Care Programme Approach (CPA) assessment from the relevant purchasing authority. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to assess and reflect changes in peoples’ support needs, the risk situations they experience and are supported to make decisions about their own lives. EVIDENCE: Since the last inspection report the care planning system had improved that aimed to be more person centred in recording how people wanted to be supported and be involved more fully in the deciding their own goals and support needs. A ‘Keyworker’ system had been introduced where a named member of staff would work more closely with a person to regularly review the support they received and to raise any concerns or changes in their needs. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 11 Care plans were sampled and they provided clearer and more detailed information about the person, their needs, goals and the support they required. The information was more focused on the how the person wanted to be supported and recorded in a person centred style that read as if the person was describing their support needs. Examples were found of multi-agency working with updated and ongoing reassessment of peoples’ needs and support guidance for staff to follow. To show that the new care planning system continues to be based on the principles of person centred planning it is recommended that the home maintain evidence of how people are involved and consulted in developing their own care plan. The care planning process included a review system where care plans would be updated, where required, every four months. The care plans had been reviewed in June 2007. In addition, each person’s support was reviewed through the purchasing authorities own review process including the Enhanced CPA. It is recommended that each person’s working file is reviewed and edited to ensure that only the most recent and relevant information is available for staff to refer to. Any restrictions of choice placed on people were based on a risk assessment and support plan to make sure that the person was not placed in unsafe situations. Staff where seen to encourage and support people to make decisions and choices about their day-to-day lives such as activities and meals and encourage people to become involved in keeping their own space and the house clean. One person was supported and encouraged to manage their own personal finances and the others were fully supported. The staff were being provided with information regarding the implementation of the Mental Capacity Act 2005 and its impact on their work in supporting people to make decisions and to take meaningful risks. The care planning system included a process for identifying and recording risks and hazards that people may experience. Examples were seen where the home had worked with specialist healthcare providers to identify risk situations and to develop ways to support people to minimise those risks so enabling them to take part in activities they enjoyed and to make sure that people maintained their emotional health. It is recommended that all staff (including agency staff) clearly evidence that they have read and understood relevant risk assessments and support guidance to ensure consistency of support. 111 Crescent Road DS0000021703.V334651.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, 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. EVIDENCE: Between 9:00am and 5:00pm there were usually three staff available to provide support for people to take part in home or community based activities. With three people living at the home the staff ratio of 1:1 should mean that people have the opportunity to experience a range of meaningful valued activities. Since the last inspection report a member of the staff team had been given the responsibility for finding out information on activities and facilities that people could access in the community. Each person’s care plan now included clear information about their interests in and activities they enjoy participating in. Examples were seen of how the home had sought and supported people to take part in culturally relevant activities and had also worked with other
111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 13 specialists to develop clear and structured programmes of activities that met the person’s individual needs. Records of these activities and the 1:1 support offered were being maintained. People were supported and encouraged to maintain links with their families where possible. Visitors were welcomed at any reasonable time and could use both communal and private areas. With three staff on during the day to support three people each person should be able to set there own routines depending on prior arrangements such as health appointments. People have their own keys if the wish and mail was always given direct to the person unless they required help. People had the choice to spend time with others or in the privacy of their own rooms. The home also had two separate lounges and a kitchen/diner that allowed people to choose where they wanted to spend their time. People were encouraged to decide what they wanted for meals and it was seen that different choices were offered at all times. The meals provided were based on a persons likes and dislikes and their health needs. Eating and drinking guidance and guidelines had been developed to support a person at mealtimes. It is recommended that only the most recent and relevant guidance regarding eating and drinking be maintained in a person’s working file to ensure that the correct support was being provided. 111 Crescent Road DS0000021703.V334651.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs are supported by the home. However, the systems and practices for the administration of medication do not fully protect people. EVIDENCE: People were encouraged and supported to maintain their personal care as far as possible. Some ‘hands-on’ support was provided and this support was clearly recorded within individuals care plans. The home continued to support people to maintain their health and wellbeing through accessing general and specialist healthcare providers. Records of health needs were clear and detailed in the persons care plan. General and mental health related appointments were recorded. Medication needs were regularly monitored through the local G.P or allocated psychiatrist. Evidence was seen how improvements in peoples’ lifestyles and choices had been made through changes in medication and through reductions in the need for specialist healthcare input.
111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 15 The previous inspection reports had highlighted issues with the use of liquid thickeners. Evidence was seen, in a person’s working file, of two separate Speech and Language Therapist guidance that gave different instructions on its use. It was also found that the use of thickener was not being fully recorded to show its administration. The guidance for the use of liquid thickeners must be clear and current to reflect peoples’ needs and its use must be recorded to show that it has been administered in the correct way. The Medication Administration Records (MAR) were sampled and found that the records were mostly accurate in detailing the administering of medication. Medication prescribed ‘as required’ (PRN) was supported with administering guidance. Medication levels were being audited on a regular basis to show that people had received all the correct medication. However, there were some areas that of the medication administration system that required improvements. Not all medication prescribed as PRN was not clearly recorded as such on the relevant MAR sheet and the recording did not clearly reflect what time the medication was administered. Some PRN medication guidance was not clear and its use was not clearly understood by staff responsible for administering medication. The previous inspection report highlighted that staff had received refresher medication training that they found did not cover the specific medication that they used at the home and also did not cover all aspects of medication administration and recording. Staff on duty stated that they had raised the issue of needing further medication training with the main organisation who manage the home (The Regard Partnership). The previous requirement that staff who work at the home must have the skills, awareness and competence of their roles and responsibilities for the medication administration systems was reiterated. 111 Crescent Road DS0000021703.V334651.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the policies and procedures in place and the staff were aware of the practices to respond to peoples concerns and to protect them from harm. EVIDENCE: The home had a clear complaints procedure and people have been provided with information about how to raise their concerns and worries. The policy had been updated to include the contact details of the CSCI. People were able to raise any concerns they may have with others outside of the home such as social workers and other health professionals. Since the last inspection report the CSCI had not received any formal complaints regarding the service. The home has an Adult Protection Policy and adheres to the Manchester MultiAgency Adult Protection Procedures. Staff were aware of the issues around adult protection and were able to clarify the procedures to be taken in the event of an incident or concern. The home had developed and introduced a new set of guidelines for the support of peoples’ personal finances and monies. This set out the procedures for staff to follow and the auditing system. Finance records were checked and found to be accurate and to be following the set procedures. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment and premises of the home meets peoples needs and is generally clean and of a homely nature. However, areas of the home are not up to standard and the practices and procedures for infection control do not fully protect people. EVIDENCE: A tour of the building showed that the home was generally clean and reasonably maintained. The layout of the building offers people the flexibility to allow them both communal and private space. It was found that work had been carried out to repair and replace items raised through previous inspection reports. The kitchen extractor had been fixed and kitchen window glass replaced. Several areas of the home had been rearranged to better suit people’s needs and had been decorated. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 18 However, a number of areas still required attention. The ground floor toilet regularly became blocked and needed attention. The 1st floor toilet had broken tiles on the walls. The 1st floor bathroom had discoloured grouting, broken tiles and was in a general state of poor repair and required decoration. The areas identified above must be rectified and an audit of repairs and an action plan for refurbishment and decoration must be submitted to the CSCI. A domestic washing machine, located in the kitchen, was used for all peoples’ clothes and linen. The staff on duty described the infection control practices they use with soiled clothes and linen. It was found that some of the practices could cause cross infection as soiled items were all carried through to the kitchen in a plastic laundry basket. The procedures and practices for infection control must be reviewed, updated and staff made aware and competent in safe working practices. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a staff team who generally have the values and understanding to support their needs. The recruitment systems in place make the required checks to safeguard people and the home have the systems in place for training the staff team. EVIDENCE: At the time of the inspection site visit the staff team consisted of six regular support workers with additional staff used to cover for holidays, training and sickness. During the day three staff were on duty to provide people with a 1:1 support when required. The staff rota showed that agency staff were still being used and one was on duty at the time of the site visit who had never worked at the home before. Due to the complexity of people’s needs it is recommended that the home minimize the use of agency workers to ensure a consistent staff team approach to supporting peoples complex needs. The majority of the regular staff team were currently undertaking or had completed the NVQ Level 2 and/or 3 vocational qualification. The staff on duty
111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 20 were asked about their role and the work they do with people and they were knowledgeable and able to show that they understood people’s support needs. The recruitment process and procedures were operated by the main organisation, Southfields Care Homes Ltd T/A The Regard Partnership. Due the organisation having a national coverage it was agreed with the CSCI for all staff personal files and documentation relating to recruitment to be kept at the organisations main head office and to be inspected by a senior representative of the CSCI. The manager of the home and the senior management team carried out local recruitment of support workers. The training schedule provided by the company that manages the home and included dates for an Induction programme, mental health, and care planning training. The Induction training programme was based on the Skills for Care Induction modules. Staff on duty were asked about the training that they had undertaken since the last inspection. Work had been undertaken in relation to understanding people’s mental health conditions. The manager had undertaken a training audit and identified gaps and the need for refresher training. Each member of staff had a training plan. The issue of the need for more relevant medication training had been raised previously in the report. It is recommended that the home provide the CSCI with an updated audit of the staff training undertaken and required and training schedule. It is recommended that staff continue to access and participate in training to meet people’s support needs and that a system is introduced that assesses the competence of staff to ensure that they have understood and correctly apply the training they received. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek peoples’ views of the service and to maintain their health and safety. EVIDENCE: The current manager had been in post for around 7 weeks. The manager had responsibility for two other small care homes all within a short distance of each other but was based at this home. They had several years of management experience including being a registered manager at another care home, gaining the Registered Managers Award in 2003. They had experience in working with people with learning disabilities,
111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 22 autism and mental health issues and were also developing their knowledge and skills through further study. They stated that they were aware of the need to apply to become the registered manager and had the relevant documents to complete. The manager must submit an application to become the registered manager of the home as required by the Care Homes Regulations 2001. The manager stated that they were aware of the issues and concerns regarding the home that have been identified through previous inspection reports. They stated that were supported to achieve these changes through her senior management but acknowledged that she had not had any formal supervision herself. It is recommended that the manager have access to regular and ongoing formal supervision to ensure that the managers own development needs and the progress in developing the service are clear and defined. The home has an established system of quality assurance undertaken by the company’s Quality Manager. This involves regular Regulation 26 visits to the home and undertaking ‘mock’ inspections to assess how the home is meeting the National Minimum Standards. The home also undertake an annual and ongoing ‘Satisfaction Surveys’ to gain the views of the people living at the home, relatives, carers and other relevant professionals. The manager stated that they had introduced a system where each month staff would spend time with each person to find out how they felt about the service and any concerns or problems they may have. Examples of these sessions with people were seen and showed that issues and concerns were being raised and dealt with. A fire log was maintained for visual checks and fire drills. A fire risk assessment had been reviewed. Up-to-date environmental risk assessments had been undertaken in relation to the health and safety of the home. Records for monitoring temperatures of the hot water and fridge/freezer were being maintained. 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 23 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement All staff that work at the home must have the skills, awareness and competence of their roles and responsibilities for the medication administration systems. (Timescale of 01/11/06 was not met). All medication prescribed as PRN must be clearly recorded as such on the relevant MAR sheet and the recording must clearly reflect what time the medication was administered. PRN medication guidance must give clear unambiguous guidance on its use that can be clearly understood by staff responsible for administering medication. The guidance for the use of liquid thickeners must be clear and current to reflect peoples’ needs and its use must be recorded to show that it has been administered in the correct way. The home must ensure that the following issues identified in the report are addressed and an
DS0000021703.V334651.R01.S.doc Timescale for action 30/07/07 2. YA24 23 30/07/07 111 Crescent Road Version 5.2 Page 25 action plan supplied to the CSCI within the timescales stated: 1. The redecoration of parts of the home identified in the report. 2. Make good the repairs and refurbishment identified in the report. (Timescales of 21.08.06 and 01/11/06 was not met). 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 YA6 Good Practice Recommendations To show that the new care planning system was based on the principles of person centred planning it is recommended that the home maintain evidence of how people are involved and consulted in developing their own care plan. It is recommended that all staff (including agency staff) clearly evidence that they have read and understood relevant risk assessments and support guidance to ensure consistency of support. It is recommended that only the most recent and relevant guidance regarding eating and drinking be maintained in a person’s working file to ensure that the correct support was being provided. Due to the complexity of people’s needs it is recommended that the home minimize the use of agency workers to ensure a consistent staff team. It is recommended that the home provide the CSCI with an updated audit of the staff training undertaken and required and training schedule. 2 YA9 3 YA17 4. YA33 5. YA35 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 26 6. YA35 It is recommended that staff continue to access and participate in training to meet people’s support needs and that a system is introduced that assesses the competence of staff to ensure that they have understood and correctly apply the training they received. It is recommended that the manager have access to regular and ongoing formal supervision to ensure that the managers own development needs and the progress in developing the service are clear and defined. 7. YA37 111 Crescent Road DS0000021703.V334651.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Regional Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU 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
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