CARE HOME ADULTS 18-65
111 Crescent Road 111 Crescent Road Crumpsall Manchester M8 5SH Lead Inspector
Steve O`Connor Unannounced Inspection 4th September 2006 11:00 111 Crescent Road DS0000021703.V310769.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.V310769.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.V310769.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 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.V310769.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 disaorder (MD) 4th July 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. The smoking lounge is also used as sleep-in room and contains a single bed. 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; these 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 (Southfield Care Homes Ltd). 111 Crescent Road DS0000021703.V310769.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 June 2006. This information includes an Action Plan sent in response to the inspection report, During the site visit time was spent observing how staff work with people who live at the home, taking to staff on duty and a registered manager from another care home, in the same organisation, who was providing management cover. Documents and files relating to people and how the home is run was also seen and a tour of the building was made. The inspection report of June 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 some improvements in those areas. These will be shown through this report. The inspection was another 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 needs to do with the home. What the service does well:
An area that the home continued to take seriously 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. The home 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. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
People who live in care homes do so for a variety of reasons but generally they need help and support to allow them to live as independently and safely as possible. Care homes must show that they understand what help people need and so they should develop care plans that sets out clearly, and in sufficient detail, all the needs and goals that people have and how they are going to support the person. Care plans should be regularly reviewed to see if they are still working and takes into account any changes in people’s needs. The home has made progress introducing a new way of identifying and recording people’s needs and support. However, this has only recently been started and not everyone has a new care plan. Also, the new way that the home reviews and looks at how well it has supported people has not yet started and this needs to be looked at over the next inspection. Generally, the home provides people with the support they need to help them to stay healthy in their general and mental health. If people have special needs, such as needing help with their eating and drinking, then the staff will follow guidance written by a specialist health person, such as a Speech and Language Therapist. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 7 It was found that the home were not following guidance set down in relation to the thickness of drinks that a person can have. This could place the person’s health at risk. At the last inspection the home were told that they must make sure that the guidelines were being followed correctly. They had not done this and so the requirement was repeated again in this report. To help people keep well and healthy, especially their mental health, the home supports people to take the right medication at the right times. To do this the home has a medication administration system that should make sure that medication is given safely, all aspects of medication are recorded correctly and that staff have the skills, knowledge and competence to make sure that the system is working. The previous inspection report highlighted that there were some problems with the home’s medication administration systems. Whilst the home have put some of these areas right there are still two areas that need to be improved. The first is to make sure that all staff who administer medication have the skills, knowledge and competence needed to do so safely. Staff who had attended a medication training event stated that the training was rushed, involved giving out lots of handouts and did not cover the medication they work with or certain key areas of the medication administration system such as Medication Administration Records (MAR). The second area is to make sure that the home has a formal auditing system to ensure that regular checks can be made to make sure that medication has been administered correctly. It is the responsibility of the home to provide people with a clean, comfortable, safe and homely environment in which to live. Generally the home is clean and the layout of the building allows people to spend time together and in private. However, the last inspection report pointed out that home’s decoration and furnishings are looking worn, tired and outdated. Also, a number of specific areas were highlighted that needed either repair or replacing. After the last inspection report of July 2006 the company that runs the home had sent the CSCI an Action Plan on how they were going to put right the areas that needed changing. The plan stated that all the outstanding maintenance requirements and redecoration of the home are addressed. During the inspection site visit it was found that some decoration and replacement of worn furniture had been carried out. However, a number of areas identified in the July 2006 inspection report had not been completed. The home were asked to look at these areas again and make sure that they take the action needed to improve people’s environment. The home has experienced problems appointing a manager for over a year. The inspection report of July 2006 highlighted that a person was offered the position but they had to withdraw from the offer.
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 8 When this happened the main organisation decided to ask the manager of another care home they operate to provide management cover for her own home plus this home (111 Crescent Road) and another two small homes (that are next door to each other). The CSCI was assured that this would be a short-term arrangement as it was felt that a manager splitting their time between four small care homes would not provide the management leadership that the homes needed. At the time of the inspection the CSCI were told that a manager had been appointed but there was no date for when they were going to start. The home have a responsibility for keeping people as safe as possible while they live at the home. The last inspection report highlighted a number of changes that home had to do to make sure that everyone was living in a safe home. A number of improvements had been made but some had not. These included visual checks for means of escape in an emergency, no alternative forms of emergency lighting and no environmental safety checks being made. The home must put these things right. 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. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 9 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.V310769.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. 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.V310769.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does encourage people to make choices and decisions that affect them and that people are supported to cope with hazards and risks in the safest way. However, they do not yet have the systems to ensure that care plans fully reflected peoples’ needs and goals. EVIDENCE: Since the last inspection report the home had introduced a new care planning system that aims to be more person centred on how people want to be supported and be involved more fully in the deciding their own goals and support needs. The home had completed two of three people’s care plans and they provided clearer and more detailed information about the person, their needs, goals and the support they required. There was also clear review dates set but as the care plans had only recently been developed no reviews had yet taken place.
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 12 This work showed an improvement on previous care plans but as all the plans had not been completed the requirement was reiterated. 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. Any restrictions of choice placed on people was based on a risk assessment and support plan to make sure that the person was not placed in unsafe situations. Staff would 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 is supported and encouraged to manage their own personal finances and the others are fully supported The new care planning system also included a new way of identifying and recording risks and hazards that people may experience. The previous inspection report had noted that the way that staff worked with people to help minimize risks was not fully reflected in people’s risk assessments and support guidance. These had now been improved and included clear and detailed information. This action met the previous requirement. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People had access to the support to develop their own routines and maintained links with families and friends if they wanted to. People were offered meals they enjoyed and were provided with the relevant support. The home was not able to show fully that it was offering people valued and meaningful opportunities. EVIDENCE: Between 9:00am and 5:00pm there are three staff available to provide support for people to take part in home and 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. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 14 As part of the new care planning process the home had developed a format for recording the 1:1 support and activities that people participate in or are offered. The aim was to provide more information in how the support and activities that people take part in relates to their identified needs and goals. The quality of this information was discussed with the home and found that the level of detail and information recorded varied between staff. There had been improvements made to the recording and support systems, however, the varying quality of the recording means that the requirement needs to be reiterated. 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 is always given direct to the person unless they require help. People have the choice to spend time with other people 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 that wanted for their 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. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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 most of their healthcare needs are supported by the home. However, not all people’s health needs are being appropriately met and the home’s systems and practices for medication administration do not fully protect people. EVIDENCE: People were encouraged and supported to maintain their own personal care as far as possible. Some ‘hands-on’ support was provided and this support was recorded within individuals care plans. The home supported people to maintain their healthcare through accessing general and specialist healthcare providers. Records of health needs were maintained in the persons care plan. General and mental health related appointments were recorded. However, the outcomes of the health appoints were not always recorded in any detail. It is recommended that the outcomes of people’s health related appointments be clear recorded in sufficient detail. Medication needs were monitored through the local G.P or allocated psychiatrist.
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 16 The previous inspection report highlighted that guidelines regarding a person’s swallowing and use of thickeners was not being followed by the home. They were required to ensure that they had the most up-to-date guidelines and clarify the use of thickeners. The guidance was present in the person’s file but the home had not clarified the use of thickener. Therefore the requirement was reiterated. The previous report also highlighted some concerns regarding the medication administration systems. There was now clear guidance on the use of medication ‘as required’ (PRN), the Medication Administration Records (MAR) were accurate and fully signed. And the home now had full responsibility for the ordering of medication and prescriptions. Through discussions with staff it was found that they had recently received refresher medication training but they found that the training did not cover the specific medication that they used at the home and also did not cover all aspects of medication administration and recording. This issue of staff awareness and knowledge had been raised in the last inspection report. Staff who work at the home must have the skills, awareness and competence of their roles and responsibilities for the medication administration systems. It was also found that the home did not undertake regular formally recorded audits of the medication stocks and records to ensure that all medication was being administered safely. A requirement was made to address this issue. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to raise their concerns and worries. However, the home does not have the systems, procedures and practices in place to be able to fully protect people. EVIDENCE: The home has a clear complaints procedure and people have been provided with information about how to raise their concerns and worries. A number of complaints/concerns had been received by the CSCI and other agencies in relation to the home. These had been fully investigated by external agencies and had been found unsubstantiated. 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 last two previous inspection reports found errors and discrepancies with the spending recording of people’s personal monies. The home was required to undertake a full audit of people’s monies and ensure the policy and procedures for recording, auditing and monitoring were clear. An audit had been undertaken and the recording of people’s spending and monies was accurate. However, evidence could not be found to show that the
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 18 policy and procedures had been updated to include a clear procedure for recording and auditing. This requirement was therefore reiterated. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home was generally clean the general condition, decoration and maintenance of the building was not of a satisfactory standard. 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. The previous inspection report highlighted a number of areas that required either repair or redecoration to improve the quality of people’s environment. A number of the improvements had been made but a number were still outstanding. However, the home had provided the CSCI with an action plan in response to the previous inspection report and this stated that all identified outstanding maintenance and redecoration had been addressed. This was not evidenced during this inspection site visit. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 20 The home stated that plans for decoration and refurbishment of some rooms and new furniture were in place but these had not yet been actioned and there was no timescales for action. Therefore the previous requirements were reiterated and the home must provide the CSCI with a clear and detailed action plan for the decoration and refurbishment of the home. The previous requirement relating to the provision of appropriate infection control equipment had been addressed. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. 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 team with sufficient cover 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 five regular support workers with additional staff used to cover for holidays, training and sickness. Due to staff taking holidays the home was using a higher level of agency workers. Since the last inspection report there has been incidents that give concern as to the quality of some of the agency staff who work at the home and the need to be able to apply and work with people who present challenging behaviours. 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. The home stated that all the regular staff team were currently undertaking or had completed the NVQ Level2 vocational qualification. The staff on duty were
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 22 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. The documentation and checks required were maintained at the main office and samples of these files had been seen on the 10th July 2006. Files were seen with completed application forms, references received and a contract of terms and conditions. The procedure for obtaining the required Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) check had been updated. Staff were spoken to regarding the training they had undertaken. One staff described the induction process and that it had covered a wide range of areas. The home had identified that the core training staff required included the Induction, Adult Abuse, Health and Safety, Food Hygiene, First Aid and Medication. In addition previous requirements from inspection reports had highlighted the need for staff to have training in Challenging Behaviour. The home has shown a commitment to providing staff with the required training and this was still in progress. It is recommended that the home provide the CSCI with an updated audit of the staff training undertaken and required and an updated training schedule. The national training body for the social care sector, Skills for Care, have introduced a new Induction Programme that all care staff must undertake. It is recommended that the home provide the CSCI with their Induction Programme to show that the required changes have been made. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has the systems in place to seek peoples’ views on the quality of the service they received. The management provision of the home is not sufficient to effectively manage the home and the home does not have the systems and practices in place to maintain people’s health and safety. EVIDENCE: The last four inspection reports have highlighted the need for the home to have a permanent manager appointed who should apply to become the registered manager. The management arrangements put in place by the home are that an experienced registered manager from another care home, operated by the main organisation, would provide some on-site management cover and to be available to oversee the operation of the home. In addition, members of the senior management team would offer off-site support to the manager when
111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 24 required. Whilst this does give the staff team some support and management direction the arrangements mean that the one manager is actually covering her own service plus three small care homes. The home have made an appointment of a new manager but were unable to give a date for them starting work. The current management arrangements do not provide the home with the consistent leadership it requires and so people do not benefit from a well run home. The home must appoint a manager who is fit to manage a care home. It is also recommended that the home provide the CSCI with the date for the new manager starting work at the home. The organisation that operates the home (Southfields Care Homes Limited T/A Regard partnership) have a clear quality assurance system that includes regular regulation 26 visits by the Quality Assurance Manager, formally seeking people’s views on the service they receive and have undertaken an audit of how the home is meeting the National Minimum Standards. The previous inspection report highlighted that the smoke detectors had not been regularly checked. This was now being carried out on a monthly basis. Other checks on regarding the fire safety systems are being made. However, it was noted that the new recording format used does not include checking the means of escape. As the home had no emergency lighting the home needed to ensure that they provided staff with the required equipment in cases of emergencies. This had not been actioned. Therefore the requirements were reiterated. In addition the home must provide the CSCI with an up-to-date fire risk assessment. The health and safety environment audit checks were not being carried out. 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 25 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 1 X 3 X X 2 X 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement Care plans must reflect fully people’s needs/goals and support and be reviewed on a regular and ongoing basis based on the person’s own individual circumstances and to reflect changes in people’s needs/goals. (Timescale of 21.08.06 was not met). The home must ensure that all social, leisure, domestic and community based activities are fully recorded. (Timescale of 21.08.06 was not met) The home must ensure that staff has access to and full understanding of all health guidelines and guidance and that they support people according to those guidelines. (Timescale of 21.08.06 was not met). 4. YA20 13 1. All staff that work at the home must have the skills, awareness and
DS0000021703.V310769.R01.S.doc Timescale for action 01/11/06 2 YA13 YA12 15 01/11/06 3 YA19 18 01/11/06 01/11/06 111 Crescent Road Version 5.2 Page 27 5 YA23 13 competence of their roles and responsibilities for the medication administration systems. 2. The home must develop and implement a formal recorded auditing system for the medication administration system. The policy and procedures for managing people’s monies must contain clear procedures for the recording, receipt, auditing and monitoring. (Timescale of the 14/04/06 and 21.08.06 was not met). 01/11/06 6 YA24 23 The home must ensure that the 01/11/06 following issues identified in the report are addressed and an 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 identified in the report. 3. Replace the damaged items identified in the report. 4. Put in place the changes to the use and layout relating to the sleep-in arrangements. (Timescales of 21.08.06 was not met). The home must appoint a manager who is fit to manage a care home. The home must ensure that it has the fire safety recording procedures that protects people. The home must have the necessary equipment and aids to respond to emergency situations. 7 8 YA37 YA42 8 13 01/11/06 01/11/06 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 28 The home must have the monitoring systems in place to ensure the safety of the environment. (The timescales of 21.08.06 for the above requirements were not met). The home must provide the CSCI with an up-to-date Fire Risk Assessment. 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 the outcomes of people’s health related appointments be clear recorded in sufficient detail. 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. It is recommended that the home provide the CSCI with the Induction Programme to show that the required changes have been made. It is recommended that the home provide the CSCI with the date for the new manager starting work at the home. 2 3 4 5 6 YA19 YA33 YA35 YA35 YA37 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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 111 Crescent Road DS0000021703.V310769.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
