Inspection on 05/09/06 for 30 Keepers 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 Good. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

30 Keepers Crescent 06/06/07

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Keepers Crescent Off Redhill Way Donnington Telford Shropshire TF2 9NZ Lead Inspector Rebecca Harrison Key Unannounced Inspection 5th September 2006 09:35 Keepers Crescent - New Era DS0000066735.V296545.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 Keepers Crescent - New Era DS0000066735.V296545.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. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keepers Crescent Address Off Redhill Way Donnington Telford Shropshire TF2 9NZ 01952 201 715 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.dimensions-uk.org Dimensions (UK) Ltd Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last inspection 2nd February 2006 (UNDER THE PREVIOUS REGISTERED PROVIDER) Brief Description of the Service: Keepers Crescent is a purpose built home situated in a residential area of Donnington, Telford. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of five adults with a learning disability. The home opened in 1996 and is owned by Bournville Village Trust. Dimensions (UK) Ltd is the new service provider and was registered with CSCI on 1st April 2006. The responsible individual is Ms Susan O’Loughlin. A new manager has recently been appointed and is due to commence work on 18.09.06 and will thereafter apply for registration with CSCI. Service users are provided with a single bedroom without en-suite facility. All bedrooms are situated on the first floor and a passenger lift is provided. A large enclosed garden is available to the rear of the property, providing seating, a summerhouse and a vegetable garden. The home is close to local facilities and a just a short journey from the main Telford Shopping Centre. The current range of fees charged was not readily available at the time of the inspection. The organisation has a block contract with the local authority to provide care and accommodation based on full occupancy. The home currently has one vacancy. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by two inspectors over four hours. The inspection included talking with service users, the area manager, staff on duty, case tracking two people, observation of some work practices, examination of a number of records and a full tour of the home. 22 key National Minimum Standards for younger adults were assessed during this inspection in addition to standards 1,4,5,14,21,27 and 36 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The service users, area manager and staff on duty were welcoming and cooperated fully throughout the inspection. The purpose of this unannounced inspection was to take into consideration the six requirements made under the previous provider at the last inspection undertaken 02.02.06 and to review the progress made under the new registered service provider. No complaints have been received by the home or referred to the Commission for Social Care Inspection. Two referrals have been made under adult protection procedures and Joint Review meetings held. What the service does well: Staff on duty reported that service users were well supported during the change of registered provider. It is difficult to accurately represent the views of the people using the service in relation to the quality of care they receive given the service users abilities and the limited opportunity to fully observe staff practices in the limited time people were present at the inspection. However brief discussions held with staff on duty indicate that people are supported by a committed and motivated staff team who have a good understanding of service users individual needs and have developed positive working relationships with the people they support. People are provided with very good opportunities to access the community and partake in a number of activities. Links between service users and their families are well established and promoted. Minutes of the service user minutes were reviewed and demonstrated that service users are consulted and involved in decision-making processes relating to their support and their home. Keepers Crescent - New Era DS0000066735.V296545.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. Keepers Crescent - New Era DS0000066735.V296545.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 Keepers Crescent - New Era DS0000066735.V296545.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives have the information required to choose a home and their needs are assessed and introductory visits offered to ensure an appropriate placement. EVIDENCE: A Statement of Purpose has been developed for Keepers Crescent and was reviewed by the inspector and found to contain all required information, with only two minor amendments required. The address of the home was incorrect and the information detailed in relation to the organisations supported living service was possibly misleading. The area manager committed to changing both these details. One person has been admitted under the new registered provider. The persons care documentation was reviewed as part of the case tracking exercise and contained an Overview Assessment undertaken by the placing authority in addition to an assessment of need conducted by the deputy manager. Records clearly evidenced introductory visits to the service and outcomes in addition to a planning meeting held with the individual, parents, an advocate, the deputy and area manager. Observations made and discussions held with staff on duty indicate that the person has settled in well to the home and compatible with existing people. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 9 Draft generic contracts between the new registered provider and individual service users have been developed however it was reported that an independent advocate has requested these be more individualised prior to being issued. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning systems require further development to ensure service users assessed needs are fully met. Service users are appropriately supported with making choices and enabled to take responsible risks. EVIDENCE: Two people were case tracked and their care files reviewed. Overview assessments were available on each file and the home is in the process of introducing new documentation entitled ‘About Myself’ which provides staff with information in relation to individual support requirements. The area manager was advised to develop these further as records seen do not clearly state the level of support an individual requires when undertaking personal care tasks. Daily records seen were comprehensive. A Person Centred Plan was available on the one file reviewed which had been developed by the previous Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 11 provider, however the area manager reported that training will be provided for staff in order for all service users to be provided with a plan. Support plans and daily records seen indicate that service users are appropriately supported with making decisions and offered choice wherever possible. A communication tool was available on the one file reviewed, in addition to likes and dislikes. It was evident that the families of the two people reviewed play an active role in the lives of their relatives and their interests represented. Service users are also provided with designated key workers who also advocate on behalf of service users. Minutes of the service user minutes were reviewed and demonstrated that service users are consulted and involved in decision-making processes relating to their support and their home. There are pictures in the entrance hall of ‘Taking Part’ advocates and there is evidence that they are involved in the ‘People we support’ meetings. A variety of risk assessments were available on the file of one person reviewed for in-house and community activities which evidence that the person is enabled to take responsible risks. Only two risk assessments were available on the file of the person most recently admitted to the home to support the use of the homes vehicle and personal care. The area manager committed to ensuring all identified risks are assessed and appropriately recorded to include the management of behaviours as identified in two completed accident records. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have a community presence and lead active lifestyles. They are provided with a balanced diet, their rights and responsibilities are respected and links with families are promoted. EVIDENCE: The people living at Keepers Crescent are unable to access paid employment or work experience and do not currently attend external day service provision, therefore day activities are provided by the home. Some people have previously accessed educational courses provided by the local college and an appropriate course has been sourced for the person most recently admitted to the home and the relevant literature was available on file. On arrival to the home people were busy finishing breakfast and having drinks before preparing to go out for the day to Alton Tours. The fourth service user later went out supported by a staff member. Opportunity plans were available on the files reviewed, in addition to activity likes and dislikes and records of all Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 13 activities undertaken. Activities are planned in advance and recorded on a notice board. Records seen and discussions held evidence that service users have a good community presence and lead active lifestyles. Family links are well established and people supported to maintain contact through telephone calls and visits and all contact is recorded. Preferred routines were documented on the files reviewed and service users are supported with basic housekeeping tasks as much as possible according to their ability. It was reported that the person most recently admitted currently does not perform any domestic tasks however the team are looking towards developing the person’s skills and promoting her independence. Service users have unrestricted access to the home with the exception of one individual who due to specific reasons is unable to access the kitchen. Observations made and discussions held with staff evidence that service users rights are respected and upheld. Menus seen indicate that people are provided with a balanced diet and adequate fresh fruit and vegetables were readily available. It was reported that the people accommodated do not currently have any special dietary needs. Preferences in relation to dietary needs and support requirements were seen on the two files reviewed in addition to a record of foods eaten, which evidenced variety and choice. The area manager reported that the team are currently in the process of obtaining pictorial food charts to assist service users with menu planning and choice making. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are met with evidence of regular review with healthcare professionals. Medication procedures need to be improved to fully safeguard service users. EVIDENCE: The healthcare records of the two people case tracked evidence that their health is closely monitored and kept under review. Service users appeared well presented and preferences in relation to personal support were documented on the two care files reviewed however require further development as previously stated. Each individual is provided with a key worker to ensure consistency and continuity of support. Health records seen evidence that individuals are supported to access NHS healthcare facilities and the outcome of all appointments recorded. An appropriate referral has been made to a healthcare professional on behalf of the person most recently admitted to the home. Information has been obtained from the Department of Health regarding Health Action Plans however these have yet to be developed. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 15 Arrangements for the administration, recording and storage of medication were reviewed as part of this inspection. The procedure for the administration medication was clearly detailed and available with the recording sheets. The medication storage cabinets were well organised. Protocols for the administration of medication taken as required were available for reference. The deputy manager of the home had reviewed the protocol in June 2006. An entry in a red book that suggested that a service user had received a PRN medication on 4/9/06 could not be explained by the area manager but was clarified the day after the inspection when the deputy manager advised CSCI that the book is used for recording incoming medication. It was agreed that receipt for incoming drugs should be recorded on the Medication Administration Recording (MAR) charts to avoid confusion. A record is maintained of stocks of medications stored as controlled drugs however other stocks of medication taken on an irregular basis is not detailed. A review of the MAR sheets identified that staff sign the records appropriately however the dosage was not recorded for some medications and some medications state ‘take as directed’ with no direction available. The CSCI have been notified of three medication errors as required under regulation 37 in relation to service users either not receiving their prescribed medication or the incorrect dosage. It was reported that advice was sought from NHS Direct on all three occasions and action taken. The area manager reported that the majority of staff have undertaken accredited medication training however inspectors were unable to verify this due to certificates not being accessible. The home has recently experienced the death of one service user. It was reported that service users were supported to attend the person’s funeral and both service users and staff have been offered counselling following their loss. The home has liaised closely with the family and all agencies concerned and handled their loss in a sensitive manner. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to a complaints procedure that enables their views to be listened to and acted upon. Procedures to safeguard service users from potential abuse are in place however financial recording procedures require review. EVIDENCE: No complaints have been received by the home or referred to the Commission for Social Care Inspection (CSCI) under the new registered provider. The complaint procedure is available. A compliments book has recently been initiated and several comments were recorded to include ‘Always a warm and friendly welcome, staff very polite and helpful’. Two referrals have been made under adult protection procedures resulting in the dismissal of one staff member following an investigation with recommendations made in relation to improving financial procedures. Level Two Joint Review meetings have recently been and it was agreed to close one case and a further meeting scheduled for the other. Discussions held with a staff member of duty indicated that she had received training in the local adult protection procedure. Some staff have certificates to support that they have attended adult protection training and the rota identified staff that attended the training in August. It was reported that staff have attended training in physical intervention and will attend appropriate updates. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 17 The home’s petty cash system was up to date with staff recording that they had taken money out for the day trip. Receipts and petty cash vouchers supported entries made on the monitoring sheet however the cash balance was £20 more than recorded. CSCI were notified the day after the inspection that the staff member had taken £20 less than was initially recorded. The records of the two people case tracked were checked and were an accurate reflection of the monies held on behalf of service users however the current recording system is complex and open to error, which was fully acknowledged by the area manager who committed to simplifying the system to ensure that it is robust. The deputy manager audits the finances held on behalf of service users on a monthly basis. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 18 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): 24,27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing service users with a clean, homely and comfortable place to live. EVIDENCE: A full tour of the environment was undertaken and it was evident that people are provided with a comfortable and homely to live. It was reported that rooms throughout the home were redecorated prior to the take over of registered provider. It was reported that the landing is to be redecorated again and the area manager acknowledged the need to enhance the bathroom located on the first floor due to it being clinical in appearance and the storage of continence products need to be improved. A requirement was made under the previous provider for the shower room located on the ground floor is refurbished, which has since been undertaken. Requirements have been made at previous inspections in relation to the shower temperature, which was again tested at this inspection and reached a temperature of 57°C. The area manager committed to actioning this as a matter of urgency in addition to the vent that also requires attention. A maintenance book is in place and the area manager Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 19 committed to developing a planned programme for the renewal of the fabric and redecoration of the premises. Service users are provided with a single rooms, which were found personalised and reflect individuality. The gardens continue to be maintained to a good standard by the staff team and service users are encouraged to assist as much as their abilities allow. Service users have been involved in growing a mixture of fruit and vegetables and planting out and maintaining flowering baskets. The home was found clean and tidy during this unannounced inspection. A cleaning schedule is in place. Products hazardous to health are appropriately stored and personal protective equipment readily available. It was reported that a number of staff have undertaken training in infection control. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 20 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): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a trained, enthusiastic and committed staff team who work positively and flexibly to meet the individual needs of the people accommodated. The homes recruitment procedures safeguard service users. EVIDENCE: Interactions between service users and staff at the time of the inspection were positive. Staff were encouraging and supportive, with preparing people for their day out. Discussions held with staff on duty evidenced that they are committed to their work and were complimentary in relation to the management of the home and the new registered provider and had no concerns. It was reported that the home employs nine permanent staff. The number of staff with NVQ awards was not known, as the area manager was unable to access this information during the inspection. The personnel files for three new staff recruited by the organisation were reviewed by separate appointment at the organisations area office on 21.07.06. These files were well presented and contained relevant documentation with the exception of one file that contained written references but not from their most recent employer, which was acknowledged by the area Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 21 manager during the visit. A requirement was made under the previous provider that all personnel files contain documentation required under Schedule 2 of the amended Care Homes Regulations. A notice to the deputy manager from the organisations human resources department identified what documentation was missing from some files they had reviewed and instructions were given for the deputy manager to chase outstanding items. The file for the most recent appointment was not reviewed on this occasion. The area manager reported that one service user was supported with the recruitment of the new manager and support staff. A training record on the wall in the office identified that most staff have received mandatory training. The area manager confirmed that this record is being reviewed with gaps being addressed as courses become available. The training file contains certificates of courses attended that support this record. A staff member on duty stated that he had attended four courses recently and felt that training opportunities had improved since the new organisation took over. There was no evidence that specialist training in relation to identified needs had taken place but the area manager stated that the deputy manager is reviewing training during supervisions and personal development reviews and would be drawing up a team training plan from that information. A staff member on duty reported that she would like to attend a course in autism. Induction records were not accessible during the inspection. Staff stated that they received support and supervision to carry out their roles and a wall chart identified dates for staff to attend supervision sessions. As the deputy manager was not on shift the area manager was unable to access staff supervision files however copies of monthly supervision records were readily available on the personnel files reviewed at the area office. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management approach of the home creates an open and positive atmosphere from which the service users benefit. Aspects of performance are currently being reviewed. The premises are managed and maintained in a safe manner to safeguard service users. EVIDENCE: The area manager advised the inspectors that a new manager for the home has been appointed and due to commence induction training on 18.09.06. The deputy manager has been assuming management responsibilities in the interim and there is evidence that she has been instrumental in organising files and information to a good standard. The deputy manager arranges bi monthly staff team meetings and monthly service user meetings. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 23 A requirement was made under the previous registered provider for the views of service users, family and stakeholders are sought. Arrangements for quality assurance processes are detailed in the homes statement of purpose that references advocacy support and the use of questionnaires. The area manager showed the inspector a questionnaire that had been recently completed by a service user. The document was user friendly and outcomes reflected positively on the quality of service he receives. A report based on all views is to be developed in addition to a development plan for the service. A review of health and safety files reflected that the home has a system for making regular safety checks within the home. Water temperatures are checked twice daily and before use. All outlets are further checked on a monthly basis. As previously stated it was identified that service users are at risk of scalding in relation to shower water temperatures however the area manager agreed to action this as a matter of urgency. A requirement was made under the previous registered provider for staff to attend refresher training in safe working practices. There is evidence that staff have received refresher training in safe working practices and when the training has not taken place a date has been identified. The rota reflects that there is a first aider identified for every shift. The testing of Portable Electrical Testing was carried out on 31/08/06 by a representative of the organisation who has, according to the area manager, received training to carry out the role. Likewise all routine testing of fire fighting and other safety equipment has also been carried out over since May 2006. The record demonstrating that a fire safety evacuation had taken place did not identify how the evacuation went or who was involved. Environmental risk assessments were seen to be up to date and reviewed as required. The risk assessment for the kitchen reflects that the kitchen door should be kept closed and at the time of the inspection it was being propped open by a chair. All other risk assessments to support safe working practices were available and supported by the appropriate policy or procedure. It was noted however that the requirement made by the organisation that staff sign to say they have read and understood the assessments was not being met. Most policies seen had been signed by only three staff. The COSHH cupboard was seen to be locked with a discreet mechanism. The cupboard contained minimal products. Data sheets and risk assessments supported two of the three products identified at random. The paperwork to complete assessments of risk for COSHH products is currently being replaced by Dimensions own and it was noted that this would improve the recording of such information. It was reported that the fire officer has not visited the home since the change of provider. Environmental Health Officers have visited in relation to health and safety, which was found satisfactory. Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 24 Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x x 2 x Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 26 N/A 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 YA5 Regulation 5(c ) Requirement The registered person must develop and agree with each service user and their representative a written contract/statement of terms and conditions between the home and the each individual to include all items specified in NMS 5.2 and each service user be provided with a signed copy. Care planning systems must be further developed to ensure staff are provided with the relevant information they require to meet individual assessed needs. The home must review arrangements for the administration of medication within the home. Staff must have individual and collective training needs identified and actioned. All COSHH products must be supported by a data information sheet and a risk assessment for its use. A risk assessment must be carried out for water temperatures. Timescale for action 16/10/06 5 YA6 15(1)(2) 16/10/06 3 YA20 13(2) 30/09/06 4 5 YA35 YA42 18(1)(c) 12 31/10/06 30/09/06 6 YA42 12,13 23(2)(p) 30/09/06 Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 27 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 YA6 YA6 YA42 YA42 Good Practice Recommendations It is recommended that support plans be more detailed in relation to individual support requirements. It is recommended that person centred plans be developed for all individuals. It is recommended that this information in relation to fire drills be recorded to enable the manager to monitor the effectiveness of the evacuation plan. It is recommended that risk assessments be signed as read and understood by staff (as per the homes policy) Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Keepers Crescent - New Era DS0000066735.V296545.R01.S.doc Version 5.2 Page 29 - 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. 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