Inspection on 05/09/06 for 16 Hawthorn Crescent

This inspection was carried out on 5th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

16 Hawthorn Crescent 28/08/08

16 Hawthorn Crescent 24/09/07

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 16 Hawthorn Crescent 16 Hawthorn Crescent Worthing West Sussex BN14 9LU Lead Inspector Mrs M McCourt Key Unannounced Inspection 5 September 2006 08:30a th 16 Hawthorn Crescent DS0000067147.V298572.R02.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 16 Hawthorn Crescent DS0000067147.V298572.R02.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. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 16 Hawthorn Crescent Address 16 Hawthorn Crescent Worthing West Sussex BN14 9LU 020 8544 8900 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) www.caremanagementgroup.com Care Management Group Limited Mrs Rositsa Taseva-Mancheva Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection New registration Brief Description of the Service: 16 Hawthorn Crescent is a care home that is registered to provide care for four adults with learning disabilities between the ages of 18 and 65. The Registered Provider is Care Management Group Ltd and the Registered Manager is Rosita Taseva-Mancheva. The current scale of monthly charges are £1450.00. This information was provided by the Registered Manager. There are additional charges for hairdressing, toiletries, trips out, holidays and clothes. The home is a semi-detached property, situated in a quiet residential street, just outside Worthing’s town centre. There is easy access to all community facilities, including local rail and bus stations. The home has just finished undergoing major upgrading work that has included changing the internal structure and decorating throughout. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Tuesday 5th September 2006 and lasted a total of six hours. Pre-inspection planning took approximately two days. A full tour of the building took place and included the observation of Health and Safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Two staff members, two Service Users and the Manager were spoken to at the time of inspection. Prior to the inspection the Inspector spoke with a care manager, responsible for the care of one of the Service Users living at the home. Following the inspection the Inspector spoke with the General Manager of SCOPE. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector was able to observe staff interaction with Service Users throughout the course of the inspection. Due to the home reopening just two days prior to the inspection, it was not possible to examine all of the policies and procedures, as the home was still in the process of unpacking their paperwork. What the service does well: The Registered Manager, Mrs Rositsa Taseva-Mancheva, has managed the home since August 2002. The Inspector acknowledged how difficult recent months had been, due to the refurbishment of the two homes that she manages (16 & 18 Hawthorn Crescent). This has required her to move each house out into temporary accommodation before moving them back to their original home. All this has been carried out over a five month period, and despite the disruption this undoubtedly caused, Mrs Taseva-Mancheva has worked hard to ensure that day-to-day life for Service Users has been remained unchanged. On discussion with one of the Service Users living at the home it was confirmed that the home does involve prospective Service Users in the process of assessing suitability. Service Users spoken with also confirmed that they were aware of their care plans and one Service User said that he had been involved in the implementation of it. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 6 Annual reviews are held by social services, and review notes were seen for meetings held. For files sampled the review process is thorough and covers various matters, including, accommodation, health, mobility, finances, activities and so on. What has improved since the last inspection? What they could do better: Generally Service Users are satisfied with the service provided, although there were complaints regarding the split shift system that the home requires its staff to work. If only one Service User remains at home, this is not too much of a problem, however, if a second person stays at home it becomes difficult for both Service Users to take part in activities. Thought should be given as to how to cater for the needs of all Service Users who for one reason or another stay at home. A Service User spoken with said that if it was not for the split shifts that staff work, he would be as “happy as Larry.” On discussion with a Service User about the level of care offered, the Inspector was told that there are some difficulties getting staff to understand him. The Inspector observed at first hand that there are indeed some problems, and although it was noted that some staff have attended English courses, much more work around this issue needs to be done. Service Users attend local pubs, shops, restaurants and occasionally the cinema. Aside from these activities, there is not much on offer for them to become involved in. This was confirmed by both staff and Service Users spoken with, and again involves poor staffing levels. Prior to the inspection a concern was raised by a social worker, regarding a Service User being sent into the day centre whilst ill. Whilst on inspection the same situation arose, with the Service User being sent home due to an infection that the day centre believed to be contagious. Further investigation found that this situation is on-going, and discussions with both the Registered Manager and the day centre’s General Manager confirmed that there are indeed issues that must be resolved. Clear guidance should be provided to the 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 7 home on when it is unacceptable to send someone into the day centre, and should it be necessary for a Service User to remain at home, there must be staff available to care for that person appropriately in their own home. The home employs six staff members, only one of which has a NVQ. Training for individual staff members is in need of updating, and an annual team training plan should be implemented to match the requirements of the Service Users. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. Care Management Group took over the care provision of this home in March 2006, however Service Users still do not have Service Users Guides or contracts in place. 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. 16 Hawthorn Crescent DS0000067147.V298572.R02.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 16 Hawthorn Crescent DS0000067147.V298572.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. The outcome for Service Users was found to be adequate. Service Users’ needs are assessed prior to moving into the home. Service Users should be in possession of a Service Users Guide on admission to the home. The home should ensure a signed contract between the home and the Service User is in place, detailing breach of contract. EVIDENCE: The home does have a Statement of Purpose, but it is in the process of being updated and re-printed. There was no Service Users Guide available and one of the Service Users spoken with confirmed that he had not received one when he moved into the property. On discussion with one of the Service Users living at the home it was confirmed that the home does involve prospective Service Users in the process of assessing suitability. A placing agreement was seen for one of the Service Users, between the previous provider and the placing authority. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 10 One of the Service Users spoken with said that he had not yet signed a contract on admission to the home. The Registered Manager confirmed that no contract had been signed. 16 Hawthorn Crescent DS0000067147.V298572.R02.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. The outcome for Service Users was found to be adequate. Service Users are able to make decisions about their lives, however these are at times misinterpreted because of the difficulty in communicating with staff whose first language is not English. Staffing levels hamper daily activities if more than one Service User is at home during the daytime. EVIDENCE: Service Users spoken with confirmed that they were aware of their care plans and one Service User said that he had been involved in the implementation of it. Care plans are reviewed and the Inspector looked at a sample of these. Some are overdue their six monthly review, but the Registered Manager said that 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 12 now the Service Users were settling back into their home, reviews would be carried out soon. Service Users do have knowledge of advocacy services, and discussion with one Service User confirmed that he has used one in the past for assistance with specific issues. The Inspector observed Service Users making their own choices. However, one Service User was heard asking to go out, but staff said he must wait until the Registered Manager arrived. It was not made clear why this was the case. Risk assessments and strategies were unavailable to look at because they were still in boxes waiting to be unpacked. Generally Service Users are satisfied with the service provided, although there were complaints regarding the split shift system. Two members of staff work an early shift, one will then leave for a number of hours, returning back for the evening shift. If only one Service User remains at home, this is not too much of a problem, however, if a second person stays at home it becomes difficult for both Service Users to take part in activities. The Inspector considered that thought should be given as to how this issue can be addressed. A Service User spoken with said that if it was not for the split shifts that staff work, he would be as “happy as Larry.” 16 Hawthorn Crescent DS0000067147.V298572.R02.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. The outcome for Service Users was found to be poor. Service Users are able to access the local community and facilities, although due to staffing levels, this is somewhat limited. There are times when Service Users rights are not as respected as they should be due to communication difficulties amongst the staff team. EVIDENCE: Three of the four Service Users attend a day centre five days per week. The remaining Service User goes to a day centre two days per week. This particular Service User said that he would really like to go to college but no placement has been arranged yet. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 14 Service Users spoken with confirmed that they can receive visitors when they wish and could also choose to see them in private. One told the Inspector about his girlfriend, who he sees often. On discussion with a Service User about the level of care offered, the Inspector was told that there are some difficulties getting staff to understand him. That morning a member of staff had asked him three times if he needed to use the bathroom. Eventually another staff member interpreted the conversation on his behalf. He said that it was a frustrating moment, particularly because the discussion was irrelevant. He went on to say that he wondered if staff could explain his care plan in a language common to the team and said “it does irritate me, but it may be a way around it.” Service Users attend local pubs, shops, restaurants and occasionally the cinema. Aside from these activities, there is not much on offer for them to become involved in. This was confirmed by both staff and Service Users spoken with, and again involves low staffing levels. The Inspector was told by a Service User that he becomes bored and has passed time by wheeling himself up and down the corridor. The provider also owns the house next door, which also accommodates people with learning difficulties. The Inspector was told that on occasions Service Users are invited round to the other house to sit. It was not clear why this was, but as the staff work across the two homes, it could be interpreted as a way of keeping staffing levels to a minimum. On the day of inspection, there were two Service Users at home. One was scheduled to be at home and the other had been sent home from the day centre because of ill health. The Inspector observed that there were no activities carried out with either Service User and for the majority of the time they were just sat in their wheelchairs in the living room area. Obviously staff were busy unpacking, cleaning, running errands and so on, and at several times throughout the day Service Users were left alone. In addition, feedback received from the day centre and a care manager suggest that there are issues around staffing levels and staff comprehension of specific situations. 16 Hawthorn Crescent DS0000067147.V298572.R02.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. The outcome for Service Users was found to be good. Although Service Users do receive personal support it is not always in a manner in which they prefer. Medication procedures are in place and storage facilities are in the process of being set up. EVIDENCE: Service Users are offered individual support and were observed to be wearing clothes chosen by them. As previously highlighted, there is evidence of communication difficulties surrounding care issues. Service Users said that they can choose when to get up out of bed, and at weekends are able to have a lie-in if they wish. A diary system is used to record appointments. Once attended, the outcome is written up on a feedback sheet, held in the Service Users’ own personal file. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 16 Annual reviews are held by social services, and review notes were seen for meetings held. For files sampled the review process is thorough and covers various matters, including, accommodation, health, mobility, finances, activities and so on. Medication is not being stored properly yet, and is kept in an unlocked kitchen cupboard. On the day of inspection, a local pharmacist visited the property to advise the Registered Manager on the most suitable place to store medicines. Staff were observed giving medication, and this was carried out in a sensitive manner. 16 Hawthorn Crescent DS0000067147.V298572.R02.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. The outcome for Service Users was found to be adequate. Service Users feel their views are listened to, but more needs to be done to ensure these concerns are acted on. All concerns, regardless of how minor, should be recorded in order to track outcomes. EVIDENCE: Prior to the inspection a concern was raised by a social worker, regarding a Service User being sent into the day centre whilst ill. Whilst on inspection the same situation arose, with the Service User being sent home due to an infection that the day centre believed to be contagious. The Inspector had spoken with the Service User involved and found that he was understandably distressed with the situation. Discussions with both the Registered Manager and the day centre’s General Manager confirmed that there are indeed issues that must be resolved. Clear guidance should be provided to the home on when it is unacceptable to send someone into the day centre, and should it be necessary for a Service User to remain at home, there must be staff available to care for that person appropriately in their own home. Service Users spoken with confirmed that they knew how to complain should they need to and would speak to the Registered Manager if they had a problem. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 18 A book is used to log complaints. There were none recorded. The Inspector advised the manager that any complaints, regardless of how minor, should be recorded. There have for example been issues over the years with neighbours, which have resulted at times in written complaints. Other times the neighbours will complain verbally to staff. All of this should be recorded for future use. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. There is one copy of West Sussex County Council Adult Protection procedures available, to be shared between both 16 & 18 Hawthorn Crescent. The Inspector is of the opinion that each house should have an up-to-date copy, for easy access by staff. The home does have its own policies and procedures on abuse issues. 16 Hawthorn Crescent DS0000067147.V298572.R02.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, 25, 26, 29 and 30. The outcome for Service Users was found to be adequate. Service Users live in a homely, comfortable and safe environment. The home is clean and hygienic, but staff must make themselves aware of basic hygiene procedures. EVIDENCE: The property has been re-decorated, renovated and extended, with Service Users moving back into the house on the 2nd and 3rd September (two days before the inspection visit). Building works had not completely finished with garden work, painting and small DIY jobs still being carried out. The Inspector was of the opinion that this was potentially unsafe for Service Users. In addition there was still lots of unpacking to do, with boxes being stored around the interior of the building, making it very difficult for wheelchair users to move about freely. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 20 Adaptations and specialist equipment has been installed for the benefit of Service Users, including ceiling track hoists, wet rooms and specific equipment for individual needs. However, it was noted that in one particular Service Users’ bedroom and shower room, the ceiling track hoist has been positioned in the wrong place. The registered provider must ensure that appropriate steps are taken to remedy this situation and a requirement has been made in respect of this. Infection control awareness amongst the staff team is poor. Discussions with two members of staff and the Registered Manager revealed that they do not know what the correct temperature is for hygienically cleaning soiled laundry items. One member of staff said that she would wash soiled clothes at 40 or 45 degrees, whilst another said she would put it on a programme wash, and indicated wool, delicates and synthetics as wash programmes she would use. 16 Hawthorn Crescent DS0000067147.V298572.R02.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, 35, 36. The outcome for Service Users was found to be adequate. Staff should be suitably qualified and competent to take on the role of support worker. Service Users would benefit from a well supported and supervised staff team who have a clear understanding of the communication and physical needs of the client group. EVIDENCE: The home employs six staff members, only one of which has a NVQ. Staff work across the two houses, and a split shift system is used, whereby there is a break in the shift, and those working it will leave and return later in the day. One of the Service Users spoken with said that he did not like this system, as it cut down on the available staff. Staff meetings are held every two months, and the Inspector looked at minutes written from these. Issues discussed include Health & Safety, Service Users, training and so on. 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 22 It was noted during the course of the inspection that there are some language problems, as highlighted earlier in the report. On a couple of occasions the Inspector also experience problems in making herself understood. The Inspector sampled two files and found the relevant paperwork necessary to ensure the safety of Service Users to be in place. However, the recruitment process is affected by the company’s bureaucratic procedures. All correspondence must go through the HR department, which slows vacancy filling, especially when, as was recently the case, they lose the paperwork! Supervisions and training will need to be carried out more frequently than it has been, although it was noted that all the changes the home has currently been through has had an impact on these. There are individual training records in place, but no overall training and development plan. Annual training needs are dealt with centrally by head office. Out of the two supervision files looked at only one had a signed supervision contract. Since the company took over the home, one member of staff has received one supervision session, and the other member of staff has not received any. 16 Hawthorn Crescent DS0000067147.V298572.R02.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, 42 and 43. The outcome for Service Users was found to be good. Due to the disruption caused by building works, the Registered Manager has struggled to maintain standards within the home. The home should implement a quality assurance tool specific to the home in order to ensure the views of people involved in the home are sought on a regular basis. EVIDENCE: The Registered Manager is Mrs Rositsa Taseva-Mancheva. She has managed the home since August 2002. She is a qualified social worker in her home country of Bulgaria, having worked with children there. She has both her RMA and NVQ level 4. Mrs Taseva-Mancheva told the Inspector that she had 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 24 received lots of management training and is due to update her mandatory subjects, such as 1st Aid, food hygiene, etc. The Inspector acknowledged how difficult recent months had been, due to the refurbishment of the two homes that she manages (16 & 18 Hawthorn Crescent). This has required her to move each house out into temporary accommodation before moving them back to their original home. All this has been carried out over a five month period, and despite the disruption this undoubtedly caused, Mrs Taseva-Mancheva has worked hard to ensure that day-to-day life for Service Users has been remained unchanged. Staff, Service User and relatives questionnaires are sent out on a yearly basis. The completed forms are sent back to head office before being forwarded back to the home. They are not published. The Registered Manager said that CMG have more quality assurance systems planned, but they have not been implemented yet. Service Users meetings are held. The last one was in July 2006, before that July 2005. The Registered Manager said they are held more often, but there was no written evidence available to support this. It was noted from the minutes seen that there is no action or follow up from issues raised at the meeting. Regarding standard 42 – it was not possible to assess this because many of the homes files were still unpacked in cardboard boxes. This included their accident book, fire records, Health & Safety information and some policies and procedures. They will be looked at during the next inspection. 16 Hawthorn Crescent DS0000067147.V298572.R02.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 2 2 3 3 x 4 x 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 x 29 2 30 2 STAFFING Standard No Score 31 x 32 1 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 3 3 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 27 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 YA5 Regulation 5.2 Requirement 5.2 – The registered person shall supply a copy of the Service Users Guide to the Commission and each Service User. (a) – The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of Service Users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. (c) – ensure that the persons employed by the registered person to work at the care home receive (i) training appropriate to the work they are to perform. The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. The registered person shall having regard to the number and needs of the Service Users ensure that suitable adaptations are made, and such support, equipment and facilities, as may be required are provided, for Service Users who are old, infirm or physically disabled. Timescale for action 30/11/06 2 YA32 18(1) 30/11/06 3 YA35 18(1) 30/11/06 4 YA22 22(3) 30/11/06 5 YA29 23(2)(n) 30/11/06 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA7 YA12 YA13 YA20 Good Practice Recommendations 7.2 – staff provide Service Users with the information, assistance and communication support they need to make decisions about their own lives. 12.1 – Staff help Service Users to find and keep appropriate jobs, continue their education or training and/or take part in valued and fulfilling activities. 13.1 – Staff support Service Users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 20.6 – Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal pharmaceutical Society of Great Britain and the requirements of the Misuse of Drugs Act 1971. Foul laundry is washed at appropriate temperatures (minimum 65°C for not less than 10 minutes) to thoroughly clean linen and control risk of infection. 36.4 – staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day to day practice. 39.6 – Feedback is actively sought from Service Users about services provided through e.g. anonymous user satisfaction questionnaires and individual and group discussion, as well as evidence from records and life plans, and informs all planning and review. 5 6 7 YA3 YA36 YA39 16 Hawthorn Crescent DS0000067147.V298572.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 16 Hawthorn Crescent DS0000067147.V298572.R02.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!