Inspection on 25/07/07 for 18 Hawthorn Crescent

This inspection was carried out on 25th July 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Hawthorn Crescent 28/08/08

18 Hawthorn Crescent 26/09/06

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 18 Hawthorn Crescent 18 Hawthorn Crescent Worthing West Sussex BN14 9LU Lead Inspector John Vaughan Unannounced Inspection 25th July 11:00 18 Hawthorn Crescent DS0000067148.V341323.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 18 Hawthorn Crescent DS0000067148.V341323.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. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 Hawthorn Crescent Address 18 Hawthorn Crescent Worthing West Sussex BN14 9LU 019 0382 1868 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) wwl2_hawthorn@btopenworld.com www.caremanagementgroup.com Care Management Group Limited Mrs Rositsa Taseva-Mancheva Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: 18 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. 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 underwent major upgrading work last year that has included changing the internal structure, providing new toilet and bathing facilities and decorating throughout. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met with people using the service, staff members and the manager of the home during the visit to the service, which took place over one day. During the visit the inspector spoke to people about their experiences of the home, observed other people and staff, sampled records, interviewed staff and looked and the facilities and environment provided for people who live in the home. The inspector also reviewed information held by the commission including previous reports, incident reports and the Annual Quality Assurance Assessment (AQAA) provided by the manager of the service. The inspector received completed surveys for people who use the service and spoke to family members over the telephone. What the service does well: People benefit from an activity programme that has been put together based on their individual needs and interests which includes trips out, walks, shopping, day services, college and holidays. Generally good care plans support the people with their assessed needs and these are reviewed on a regular basis. The home has a very comfortable and relaxed atmosphere and people who use the service and staff talked openly together. The inspector saw positive contact between the staff and people who live in the home. People said they liked the food and the choices being offered. People are supported and encouraged to keep in contact with families and friends. The home is clean and tidy and free from any unpleasant smells. Rooms are light and bright and have been decorated to a high standard. People who use the service told the inspector that they were happy with their private rooms and these rooms have been significantly adapted to meet the needs of the individual. People who use the service said that they like the staff and manager and feel the support they receive is very good. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 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 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed before they can move into the home and service user agreements have been put in place however these need to be acknowledged and agreed to make them meaningful. EVIDENCE: There have been no new admissions to the home since the last inspection. The home has an admission process that ensures people have opportunities to visit the home to get to know the service and the other people who live in the service. The manager said that they are fully involved in the admission process and are confident that the service can meet the needs of the people who currently use the service. New contracts have been put in place since the last visit when the lack of agreements was noted. The contacts on file are incomplete, the section for fees is blank and the signature sections are in most cases unsigned by representative of the person who lives in the service. The provider has signed none of the agreements. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are supported by an established care planning and risk management system that responds to their assessed needs however this needs some work to improve the guidelines for one person using the service and the strategies for maintaining and supporting people to make choices. EVIDENCE: The inspector looked at three of the plans for people who use the service. The inspector. Each of these plans had information, routines and strategies for supporting the person with their personal care, healthcare and support needs. people’s likes and dislikes are noted, how they like to be supported with eating and drinking The inspector sat with one person and read through their plan and spoke to the member of staff who completed the plan on the person’s behalf. The 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 10 inspector noted that people have very complex needs and communication with new people can be more difficult however staff were observed to interact positively asking questions and acting on the response from the individual. The level of involvement of people in their plans is limited and at present the staff have not had any training is person centred planning. This training would support the staff in looking at alternative ways of involving the person in their planning utilising their communication methods and involving people who know them well. The inspector was made aware that one person has made allegations or comments about other people when they are upset and anxious this was evidenced in a letter on file, discussions with the manager and other people important to the person. This is acknowledged in the person’s plan to some extent but there is no strategy for responding to any allegations that are made. The manager was advised that they need a strategy to respond to these allegations that is agreed with the person, their representative and other people with significant involvement in their care and support. This will help to provide a clear and consistent response to any concerns raised by the person who uses the service. Risk assessment strategies are included in each of the people’s files and included access to keys, medication, moving and handling, pressure care, eating and drinking, transportation and kitchen access. The manager responded to the last inspection with plans to develop people’s involvement in making choices by implementing one to one meetings and monthly service user’s meetings. Only one recorded one to one meeting has taken place and there is one record of a service user meeting this year, which discussed holidays, activities and Christmas plans. The manager stated that this is an area that she needs to improve upon but has not had the time to complete these sessions or complete the minutes of meetings that have happened. The care plans had all been reviewed recently and care manager’s reviews could also be seen on file. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have meaningful and varied activities and improvements to the support provided at mealtimes means that people have a more relaxed and positive experience. EVIDENCE: The inspector met with people who use the service and talked to them about their activities and interests. One person told the inspector that they have a busy week out of the home. This includes going to day services and college, going to the local shops and seeing their family on a regular basis. Each person has an activity plan that includes a mixture of structured activities at college and day services or ad hoc community based activities such as day trips, shopping and going to the pub. Staff are provided from the home to support one person at their day services as they have high support requirements that the centre cannot meet at present. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 12 One person told the inspector that they are disappointed by the reduction in their activities, this is a swimming session provided at the day service that has now stopped. The manager is making arrangements for the staff at home to provide this session on an alternative day. The person has been waiting for horse riding for some time the manager explained that the person requires a specialist session and there is a waiting list for this group. The manager stated that the provision of a vehicle for the home has had a positive impact on activities for people who use the service. On the day of the visit people went out to the local shops and to the pub for a drink. This year a group of people who use the service are going to the USA for a holiday and one person has just returned from a holiday in the West Country. The inspector spoke to a family member who spoke positively about the home and the support the person receives. Regular contact is encouraged and there are no restrictions on visiting the service. A person who uses the service confirmed that they have regular contact with their family and maintain relationships with other people they know. The inspector sat and observed the lunchtime activity and part of the evening meal. Concerns were raised at the last inspection about the hurried and interrupted nature of the meal observed. The approach of staff in supporting people with their meals at this visit was very different. Staff took time to assist people with eating, people were not hurried and staff spoke to each person explaining what they were doing and asking if the person wanted extras or another drink. The boyfriend of one of the people who uses the service joined in with the evening meal. The inspector noted that the eating and drinking guidelines for one of the people who uses the service conflicted with what the inspector saw. The meal had been liquidised all in one when the person’s plan says to liquidise everything separately. The staff were aware of this when asked however the reason was that lack of “gravy” or liquid in this meal. The person did not appear distressed by this deviation from the guidelines and ate all of their meal. The manager stated that there is no shortage of gravy and sauces that can be used to meet the guidance and would remind staff of this. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported with their healthcare needs however the medication administration and recording procedures need improvements to keep people safe. EVIDENCE: The records examined confirmed that people are supported to attend appointments with healthcare professionals and each person is registered with a general practitioner. The last inspection of the service raised concerns about entries in the communication system that included times when medication had not been administered or missed. The manager had responded by stating that she had introduced new recording systems. The inspector looked at the medication administration records (MAR) and found them to be completed accurately. The medication was stored securely in a 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 14 locked cabinet. An entry in the communication record stated that they had ordered medication to replace the missing tablets. This was a significant amount of medication however the manager could not explain the entry or the reason for the medication being noted as “missing”. The manager stated that she did not believe the medication had been lost or taken, instead it had not be delivered from the pharmacy however she could find no evidence to confirm this and there was nothing to indicate that medication had been missing in the stock or record sheets. The manager stated that they would follow this issue up with the person who made the entry. People are prescribed medication for pain relief and this is not returned to the pharmacy each month. The home is not recording the stock maintained and when asked the manager could not accurately say how much of this medication should be in the cupboard. The inspector was told that the manager had implemented the new system of recording additional stock of medication on the MAR sheet however the pharmacist said that this was not a suitable use of this record. The recording therefore stopped and no other format was introduced. The manager was required to implement a record of medication held in the home that is not tracked on the medication administration sheet. A person who uses the service received medication that requires an invasive procedure. The inspector noted that there are no guidelines or protocol for this procedure. The manager stated that long-standing staff have had training in this area but new staff require this training and do not carry out this procedure. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a system of recording and responding to concerns, complaints and allegations and improvements have been made to the management of this information however further work is needed to ensure the agreed practices are followed consistently to keep people safe. EVIDENCE: The home has a system for responding to complaints, concerns and allegations with a clear and straightforward procedure that has been made more accessible to people who use the service. One person who uses the service said that they knew who to talk to if they were unhappy or concerned about anything and they told the inspector that staff are very good at helping them when they are upset about things. A family member said that they are fully aware of how to make a complaint and they said that they have always found the home and the manager to be receptive and approachable. The inspector saw a complaints log and a recent complaint from a neighbour has been fully documented. The manager has also implemented a concerns log to keep records of any other issues that have been raised. In this book the manager noted that a service user had raised an issue about how they were spoken to at college. The manager stated that they had followed this up with 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 16 the college and resolved the issue on behalf of the individual however this follow up has not been recorded fully. The manager also stated that there are issues with an individual who uses the service making comments and allegations about others when upset. This is touched on in part in the person’s plan but not significantly enough to guide people in how to respond to concerns that could be considered under adult protection procedures. This has the potential that a genuine allegation could be missed or not responded to appropriately. The manager was advised that they need a clear strategy for this person that has been agreed with the individual and their representatives on how to respond to any concerns made by the individual. During the visit to the service the inspector was made aware of a concern raised about bruising to a service user and that a representative from adult services was visiting to obtain further information. The concern was raised six days ago and this has not been reported to the commission under regulation 37. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are provided with a home that is bright, homely and comfortable and personal rooms that meet their physical needs and personal tastes. EVIDENCE: The home underwent a full refurbishment last year and an additional bedroom was provided to increase the numbers of people that can be admitted to the home from three to four. On the day of the visit the home was clean and there were no unpleasant smells. The home has an open plan lounge/dining room with a kitchen annex. The area is light and bright with a high standard of furniture adding to the comfortable and homely feel of the service. The manager commented that the provision in the kitchen area could have been better to make accessibility for the people 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 18 who use the service easier. The inspector agreed as little adaptation has been made to accommodate the needs of people with physical disabilities. Facilities for people in their private rooms have greatly improved with provision of en-suite wet rooms with bath, shower and toilet facilities, overhead tracking hoists and accessible doorways. All four people who use this service have complex needs and are wheelchair users. The inspector had the opportunity to see people’s bedrooms and people who use the service assisted him with looking around the home. People who use the service are very proud and pleased with their personal spaces. There was very clear evidence of the personalisation of these rooms with personal belongings, pictures, posters and decoration that reflected the hobbies and interests of the individuals. A separate laundry/ utility room is provided with suitable facilities to cater for the needs of people who use the service. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by a staff team who are trained and are beginning to be supervised by the manager. Further work is needed to demonstrate that the supervision is sustained and consistent and training is focussed on meeting the needs of the people who use this service. EVIDENCE: The inspector looked at the records for three of the staff who work in the home who have been recruited since the last inspection and spoke to the manager about recruitment practices. The records available in the home provided evidence that all information was is place for each person. The inspector saw evidence of two written references, application forms and proof of identity. The information on file confirmed that Criminal Records Bureau checks (CRB) and Protection of Vulnerable Adults (PoVA) checks have been completed. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 20 The inspector met with a member of staff during the visit and talked about the training and support they receive. The inspector was told that the home provides a good level of training and recently the member of staff has attended fire safety, health and safety and medication administration updates. The member of staff started a National Vocational Qualification (NVQ) two months ago and meets with one of the company assessors to support them with this award. The member of staff has had one supervision session from the manager and said that they talk about issues with people who use the service, progress on training and personal private issues. The inspector was told that the manager is supportive. The inspector observed staff during the visit and the interaction was positive and valued the individual giving the person time to respond to questions and indicate their preferences. The training records seen by the inspector confirmed that an induction programme is in place in the home, staff are training in mandatory subjects and some training related to people’s needs. The manager stated that overview training in equality and diversity is provided within the induction however more detailed training in this area is yet to be organised. Some mandatory training is due for renewal and the manager is liaising with the company’s training department to provide these updates. The inspector advised the manager that more input on the needs of people with learning disability and associated physical disability would benefit the staff team together with training on invasive procedures as discussed earlier in this report. The manager stated that she has been behind with formal supervision of the staff team but has now completed at least on session with all staff. The manager said that they intend to complete these regularly in future. The records of staff meetings were not available for the inspector to view the manager stated that a number of these meetings have taken place but they have not had the time to write up the minutes of the meetings. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced manager however further work is required to demonstrate that the home is managed effectively with a quality assurance programme that involves the people who use the service. EVIDENCE: The manager Mrs Rositsa Taseva-Mancheva is an experienced and qualified manager having completed her NVQ 4 in care and Registered Manager’s Award (RMA). Through discussion with the manager it was clear that management time is required to complete a number of outstanding actions to meet the needs of the service. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 22 The manager stated on a number of occasions during the inspection that she has not had enough management time since the changes in the service to implement areas that add quality to the services provided for people such as regular minuted meetings, one to one sessions and supervision of staff. The manager will need to address this to ensure the home continues to develop and provide good outcomes for people who use the service. At the last visit to the service by the commission the inspector confirmed that an annual survey is completed involving people who use the service, their families and representatives. There were also plans to introduce further aspects of a quality assurance programme and the inspector spoke to the manager about the implementation of these plans. The inspector was told that the organisation has a quality assurance system with specific audits and objectives to be completed each month. The manager stated that she was also had work to do to catch up with this programme and the objectives. There was an absence of records on consultation with people who use the service such as service user meetings, one to one meetings and planned key worker meetings which were all sited as improvements the manager intended to make following the last inspection and it was difficult to evidence that people’s views are being sought. The needs of people who use this service are complex however from observation and discussion the inspector confirmed that people can make their needs known and the implementation of and regularity of these forums for communication are essential to empowering people within the service. The inspector looked at the arrangements for food storage in the kitchen and found this to be satisfactory with all open foods properly covered and dated. Records confirmed that staff have had updated fire training. 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 3 X 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement An accurate record of medication must be maintained at all times. Repeated requirement previous timescale 31/12/06 partly met. Guidelines for the administration of medication via an invasive procedures must be in place. Clear guidelines must be in place to support staff in responding to allegations and concerns raised by a service user. Any incidents detrimental to the well being of the service user are reported to the commission without delay. People who use the service are supported to give their views on the service and contribute to the development of the home. Timescale for action 22/08/07 2. YA20 13(2) 22/08/07 3. YA23 13 22/08/07 4. YA23 37 22/08/07 5. YA39 22 22/10/07 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 18 Hawthorn Crescent DS0000067148.V341323.R01.S.doc Version 5.2 Page 27 - 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!