CARE HOME ADULTS 18-65
111 Crescent Road 111 Crescent Road Crumpsall Manchester M8 5SH Lead Inspector
Steve O’Connor Unannounced Inspection 9th March 2006 10:00 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 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.V286924.R01.S.doc Version 5.1 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.V286924.R01.S.doc Version 5.1 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.V286924.R01.S.doc Version 5.1 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) 20th September 2005 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 bedroom used by staff as an office and sleeping-in room. The house has gardens to the front and rear of the property; these are accessible by clear pathways. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 9th March 2006. Time was spent talking with people, the area manager, some of the staff on duty and observing how staff worked with people. In addition people’s files and other documents were inspected. A tour of the premises was also made. The previous inspection in September 2005 had identified areas that the home needed to improve upon. Most of these had been actioned and those outstanding are reiterated in this report. The CSCI had not received any concerns or complaints about the home since the last inspection. As this inspection only looked at a limited number of standards the report should be read together with the previous and any future reports to gain a full picture of how the home is meeting the needs of the people living there. What the service does well: What has improved since the last inspection? What they could do better:
The previous inspection required the home to provide guidance from the relevant health specialist regarding the response to a person’s choking risk. The timescale set of 10/10/05 was not met. Although there had been improvements to the medication administration system, there were still some areas of improvement needed. The administering guidance on all PRN medication must be updated to reflect current medication and changes in administering. In addition, all changes to people’s medication regime must be confirmed, in writing, by the prescribing doctor. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 6 Supporting people to manage their personal monies and having systems in place to keep the monies safe, is an important role for the home. There were a number of inaccuracies with the recording, accounting and auditing of people’s money and the home was required to undertake a full audit of people’s monies. In addition the policy and procedures for managing people’s monies, must contain clear procedures for the recording, receipt, auditing and monitoring and a copy of the outcome of the audit and the written procedures must be submitted to the CSCI within the timescales stated. To try to make sure that people’s health and safety is being looked after, the home must have clear procedures for notifying the organisation and other relevant bodies of notifiable incidents and staff made aware of their responsibilities. Training provides staff with the knowledge and skills they need to support people safely and in accordance to legislation, regulation and good practice guidance. Areas such as Challenging Behaviour and Food Hygiene need to be addressed for all the staff team. To make sure that the staff the home employs are safe to work with vulnerable people, the registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The role of the registered manager is to ensure that the home delivers a quality service to the people it supports and meets the organisation’s targets for quality and the National Minimum Standards. The home must submit a named person to be the registered manager of the home. The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. 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.V286924.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No Judgement was made. EVIDENCE: The core standard was assessed during the previous inspection. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 9 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): No judgements were made. EVIDENCE: The previous inspection identified that support guidance was required as a result of a person’s risk assessment that identified a choking risk. This had not been actioned and the requirement was reiterated. The core standards were assessed during the previous inspection. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 10 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): 15 The home supports people to maintain relationships with their families. EVIDENCE: The previous report recommended that the opportunities and activities offered to people were clearly recorded whether these were taken up or not. The home was recording activities offered. However, the details or relevant information about these activities were limited. The recommendation was highlighted again. 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. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 11 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): 20 The homes systems and practices for medication administration did not fully protect people. EVIDENCE: The medication administration system was checked and found that all administering recording was accurate. Medication deliveries were now being checked at the time of arrival. It was noted that guidance for administering a change of PRN medication had not been updated. A requirement was made. It was also noted that changes in people’s prescribed medication did not have any clarification or written agreement from the prescribing doctor. All changes to people’s medication regime must be confirmed, in writing, by the prescribing doctor. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 12 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): 23 The home does not have the systems, policy or procedures in place to protect people from abuse. EVIDENCE: 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 finance transaction sheets were checked with the money the home holds for each person and it was found that there were errors in recording, transactions had not been recorded, the accounting of balances was incorrect, not all transactions had relevant receipts and the balance of the records did not match the amount of money held. It was also found that the home has a policy relating to people’s finances called the ‘Care of Residents Money and Valuables’. However, this does not contain a clear and detailed procedure for the recording, monitoring and auditing of people’s personal finances. The home must undertake a full audit of people’s monies. The policy and procedures for managing people’s monies must contain clear procedures for the recording, receipt, auditing and monitoring. A copy of outcome of the audit and the written procedures must be submitted to the CSCI within the timescales stated. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 13 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): No judgement was made. EVIDENCE: The previous report required the home to carry out repairs to the bathroom and to assess the need for window restrictors. The repairs had been made and restrictor installed. The core standards were assessed at the previous inspection. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 14 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): 34 and 35 The home does not have all the systems and practices in place to show that it fully undertakes safe recruitment practices and has provided staff with the training required to undertake their role. EVIDENCE: The previous report required the home to provide staff with challenging behaviour training. A programme of training events have been planned but not all the staff had yet attended. The requirement was reiterated. 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 were assessed on the 28th February 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 POVA (POVA) check was explained and files were seen with the CRB reference number and date of issue. The use of the POVA First check was discussed and it was found that there was a misunderstanding in that it was believed that staff could start working as long as the required supervision was in place.
111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 15 It was also found that it was standard practice for the organisation to seek a POVA First for all staff. The CRB and Department of Health guidelines highlight that this check should only be made in exceptional circumstances. The registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The main organisation had given a deputy manager from another of its care homes the role of training coordinator. She was in the process of undertaking a training audit of the staff team to establish exactly what training had been undertaken and when this was achieved. The home also maintained a training log for each of the staff team. The results of the training audit and any action plan developed to address any identified training needs must be provided to the CSCI. Through discussions with the management and some of the staff team, it was stated that if staff are not on the rota on the day of a planned training/development event then they are not paid for attending that event. The National Minimum Standards identify that staff should receive at least five paid training and development days (pro-rata) per year. It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 16 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 The home does not fully have the systems and practices in place to show the home is run well, seeks people views regarding the quality of the service or fully protects peoples’ health and safety. EVIDENCE: At the time of the inspection the home did not have a named manager who could be nominated as registered manager. Management support was provided through the organisation’s management structure, who would visit the home on a regular basis. The registered provider must submit an application for a registered manager to take responsibility for the home. The issues raised through the lack of control of people’s personal finances and the issue below relating to the notification of a suspected food poisoning incident, points to the need for a manager to be appointed as a priority for the home. The home had introduced a new quality assurance system that included regulation 26 monthly reports and a ‘mock’ inspection using the National Minimum Standards and scoring. The home was also introducing an annual ‘Satisfaction Survey’ to gain the views of the people living at the home,
111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 17 relatives, carers and other relevant professionals. The progress of this system will be assessed at the next inspection. The ‘Mock Inspection’ undertaken on the 13th January 2005 identified that improvements and actions were required around a number of issues. A Regulation 26 report of the 21st February highlighted the progress of these actions. The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. The previous report highlighted the need to undertake regular fire drills. It was seen that these were taking place on a weekly basis that far exceeds the requirements of the relevant fire regulations. Fire checks of equipment were being maintained. It was noted during the inspection that an incident had occurred where it was suggested that a person may have food poisoning. A doctor was called and it was recorded that food poisoning could have occurred. The senior manager was unaware of this incident and staff were not aware of the need to notify the relevant bodies under the health and safety legislation and regulations. In addition no staff on duty during the inspection had up-to-date Basic Food Hygiene training. Procedures for notifying the organisation and other relevant bodies of notifiable incidents must be developed and staff made aware of their responsibilities. All staff must have the relevant Basic Food Hygiene training. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 18 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 X 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 X 23 1 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 2 1 X 2 X X 2 X 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 YA9 Regulation 12 Requirement Guidance from the relevant health specialist regarding the response to a person’s choking risk must be sought and implemented. A copy of the guidance to be provided to the CSCI. (Timescale of 10/10/05 not met) Timescale for action 14/04/06 2 YA20 13 1.Administering guidance on all 30/04/06 PRN medication must be updated to reflect current medication and changes in administering. 2.All changes to people’s medication regime must be confirmed, in writing, by the prescribing doctor. 3 YA23 13 1. The home must undertake a full audit of people’s monies. 2. The policy and procedures for managing people’s monies must contain clear procedures for the recording, receipt, auditing and monitoring. 3. A copy of the outcome of the audit and the written procedures must be submitted to the CSCI within the timescales stated. 14/04/06 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 20 4. YA32 18 Challenging behaviour training must be provided to all staff who work in the home. The registered provider must provide the CSCI with its policy, procedure and conditions for undertaking POVA First checks. The results of the training audit and any action plan developed to address any identified training needs must be provided to the CSCI. The manager must submit a registered manager application within the timescale stated. (Timescale of 30/09/05 not met) The registered provider must provide the CSCI with an updated action plan on the progress in meeting the identified targets from the January 2006 ‘Mock Inspection’. 1. Procedures for notifying the organisation and other relevant bodies of notifiable incidents must be developed and staff made aware of their responsibilities. 2. All staff must have the relevant Basic Food Hygiene training. 30/05/06 5 YA34 13 30/05/06 6 YA35 18 30/05/06 7. YA37 8 30/05/06 8 YA39 224 30/05/06 9 YA42 12 30/05/06 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 YA12 Good Practice Recommendations It is recommended that the home ensures that all social, leisure, domestic and community based activities are fully recorded. This recommendation also applies to standards 13 and 14.
DS0000021703.V286924.R01.S.doc Version 5.1 Page 21 111 Crescent Road 2 YA35 It is recommended that the home’s training programme include the provision of at least five paid training and development days (pro-rata) per year. 111 Crescent Road DS0000021703.V286924.R01.S.doc Version 5.1 Page 22 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
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