Inspection on 06/06/07 for 30 Keepers Crescent

This inspection was carried out on 6th June 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

30 Keepers Crescent 05/09/06

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 30 Keepers Crescent Off Redhill Way Donnington Telford Shropshire TF2 9NZ Lead Inspector Rebecca Harrison Key Unannounced Inspection 6th June 2007 09:20 30 Keepers Crescent DS0000066735.V335159.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 30 Keepers Crescent DS0000066735.V335159.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. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 30 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 vacant post Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No conditions apply Date of last key inspection 5th September 2006 Brief Description of the Service: 30 Keepers Crescent 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. At the time of the inspection the home had one vacancy. Dimensions (UK) Ltd is the registered service provider and the responsible individual is Ms Susan O’Loughlin. The registered manager is Mr Daniel Frater. Keepers Crescent is a purpose built property owned by Bourneville Village Trust and situated in a residential area of Donnington, Telford. The accommodation is based over two floors providing a lounge/dining room, kitchen, conservatory and five single bedrooms. A passenger lift is provided to aid accessibility. A large well maintained garden is available to the rear of the property, providing seating, a summerhouse, water feature and a vegetable garden. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk The current fee charged per person is £1410.10 per week. The provider has a block contract with the local authority to provide care and accommodation based on full occupancy. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 6th June 2007 and was carried out by one inspector over six hours. It included talking with people who use the service, staff on duty, the registered manager and acting area manager. The inspector looked in detail at all aspects of care provided for two people, examined a number of records and toured the home. CSCI received five surveys from service users relatives of people and one from a health professional in preparation for the inspection and their comments have been included in this report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults. Since the last key inspection in September 2006, a random inspection was undertaken in December 2006 and there was evidence that the provider was working towards meeting the requirements previously made. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The people who use the service, managers and staff on duty were very helpful and co-operated fully throughout the inspection. What the service does well: Staff have a good understanding of the individual needs of the people they support and have developed positive working relationships with service users and other agencies. The organisation is committed to providing a qualified workforce. The staff team functions well and the service is effectively managed. The home is equipped to a high standard and soft furnishings are of good quality and provide people with a comfortable and homely place to live. People who use the service are encouraged to take ownership of their support plans and staff adopt a person centred approach and have much respect for the people they support. Feedback received from surveys gathered as part of the inspection includes: ‘They appear eager to work in partnership. Service users seem to live life they chose. Staff appear friendly, listen and want to do the best for service users’. ‘Can’t think of anything more they can do that is not done already’. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 6 ‘100 care, all the staff have very high skills, 100 meets my relatives needs. Staff are very supportive. Everything is done well. I do not think the service needs to improve, as it is an excellent home in every way. The staff are excellent in all that they do for the residents and relatives. First class care home. I am more than satisfied and happy that my relative lives at Keepers Crescent and is very happy there’. 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. 30 Keepers Crescent DS0000066735.V335159.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 30 Keepers Crescent DS0000066735.V335159.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): 1 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective people and their representatives have the information needed to choose a home and are provided with a contract, which tells them about the service they will receive. EVIDENCE: The home has a Statement of Purpose in place, which was recently reviewed and updated. People who use the service have been issued with a pictorial handbook, which also includes a copy of the terms and conditions of residency. These have been produced in a format appropriate to the needs of the individuals living at the home and have been approved by an independent advocate. The acting area manager was advised to produce separate documents and to ensure the Guide meets the amended Care Home Regulations. There have been no new admissions to the service since the last inspection therefore it was not possible to assess key standard 2 on this occasion. Assessment procedures were considered satisfactory at the time of the last key inspection undertaken in September 2006. 30 Keepers Crescent DS0000066735.V335159.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. Staff are provided with sufficient information to meet the individual needs of the people they support. Service users are supported to make decisions and are to take responsible risks within a risk-assessed framework. EVIDENCE: Care documentation held on behalf of two people was examined during the inspection. Both support plans were person centred and detailed and developed in partnership with the individual and signed. The plan focuses on current needs, development of skills, and future aspirations of the individual, following the principles of person centred planning. One person had written his own support plan, which was an excellent example of practice. Both people case tracked have been formally reviewed in conjunction with the placing authority involving the individuals, their relatives and significant others. An agency member of staff spoken with during the inspection confirmed that his induction of the home included reading all care documentation and risk assessments prior to directly supporting people. People have designated key 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 10 workers for continuity of care and all staff spoken with had an excellent understanding of the needs of the people they support. Behaviour management guidelines were available and incidents appropriately recorded. People who use the service are involved in decisions about day-to-day life, the environment, staff appointments and the development of the service. A number of groups have recently been developed across the organisation to include a Regional Advisory forum and Joint Consultancy Group to assist with quality assurance and future planning and a service user from the home is supported to attend relevant meetings. Residents meetings are also held and detailed minutes were available. Records examined on two peoples files evidence that individuals are enabled to take responsible risks based on assessment. The management of risk takes into account the specialist needs of the people who use the service, balanced with their aspirations for independence and choice and ordinary living. New risk assessment/opportunity forms have been developed and staff on duty spoke positively about risk management. 30 Keepers Crescent DS0000066735.V335159.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): 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. People who use the service are supported to make choices about their life style, develop their life skills and maintain contact with their families and friends. People living at the home are provided with balanced meals in accordance with their personal preferences. EVIDENCE: The people living at Keepers Crescent currently do not attend external day service provision or access work opportunities, therefore day activities are provided by the home. The person most recently admitted to the home was supported to attend college during the inspection and it was evident through discussions held and reports seen that she is making good progress and very much enjoying using this facility. A further person up until recently also accessed the local college and hopes to restart in September. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 12 Preferences in relation to activities and meals were available on the files examined and individual activities for the day were displayed in the home, using a pictorial format. Staff spoken with stated that people have a good community presence and lead active lifestyles as evidenced during the inspection. The two people case tracked had been on holiday supported by staff. Family links are well established as evidenced in contact sheets. Feedback from the relatives of service users in preparation of the inspection was very positive. The manager reported that the team is currently developing social circles with other homes and networking with college and health and social care professionals. Staff stated that families are welcome to visit at anytime as evidenced in the visitor’s book. Families are also invited to attend social events organised by the home and the provider. Observations made evidence that routines are flexible and preferences were documented on the files examined. People are supported with basic housekeeping tasks as much as possible to develop and maintain their independence. Service users rights are promoted as confirmed by staff on duty and records examined. Rooms are lockable and one person chooses to use this facility. People are supported with attending to their personal mail. People who use the service partake in menu planning and a pictorial book has recently been developed to aid choice. The Menu displayed in the kitchen appeared well balanced in addition to meals taken during the inspection. Fresh fruit and vegetables were readily available and a number of produce is home grown. Service users are supported to take an active role in food shopping. It was reported that the people accommodated do not currently have any special dietary needs although one person is at high risk therefore a referral has been made to the appropriate health professional. 30 Keepers Crescent DS0000066735.V335159.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 good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The service provider is currently reviewing its medication policy and procedures which will improve this area of support for service users. EVIDENCE: Preferences in relation to personal support needs were detailed on the files examined for two people and all staff spoken with had a good understanding of the needs of the people they support and designated key workers are provided for continuity of care. Health action plans are currently being developed in conjunction with a healthcare professional. All appointments were clearly documented and evidence that people are supported to access NHS healthcare facilities and appropriate referrals are made as required. Feedback received from a healthcare professional in preparation for this inspection evidenced that the home are keen to work in partnership. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 14 At the time of the inspection three staff were attending in-house medication training off site. It was reported that a number of staff have undertaken distance learning training in the safe handling of medicines. Medication procedures were reviewed with a member of staff on duty and she was clearly knowledgeable of the procedure adopted by the home and staff spoken with confirmed they are happy with procedures in place. It was reported that medication would shortly be stored in people’s own rooms. CSCI’s Pharmacy inspector has recently undertaken medication audits at two of the organisations other homes in Telford and found shortfalls in the policy. The acting area manager confirmed that the policy is being reviewed by the organisation. A staff member stated that the home has developed excellent professional working relationships with the dispensing Chemist. The manager stated that a Pharmacist Technician has recently visited the home and was satisfied with the homes medication procedures. 30 Keepers Crescent DS0000066735.V335159.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 good This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Appropriate procedures are in place to safeguard service users from potential abuse. EVIDENCE: People who live at the home and their representatives have access to a complaints procedure in an appropriate format. All service users are issued with a copy of the procedure and a copy is also available in the reception area of the home. The homes complaints log was not available for inspection however the manager and staff on duty confirmed that no complaints have been made received. CSCI have not received any concerns or complaints in relation to this service since the last inspection. Several compliments were seen recorded in the homes visitors book and comments include: ‘Thanks for a good visit, good to see the good work going on to promote people’s health & wellbeing’. ‘Staff always professional and helpful. The house is well run and organised’. ‘I have really enjoyed helping the staff through their NVQ award. The staff and service users have always been welcoming & helpful. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 16 No referrals have been made under safeguarding adult procedures as confirmed by the manager and staff on duty. The local policy is available in the reception and agency staff sign to say they are made aware of the procedure as part of their induction to the home. Training records evidence that the majority of staff have attended training in the local procedure and physical intervention as confirmed by staff on duty. Financial procedures were discussed with staff who considered these to be robust and safeguard staff and service users. It was reported that people have their own bank accounts, which are regularly audited. Due to changes in the staff team bank mandates are currently being changed to enable people to have greater access to their finances. 30 Keepers Crescent DS0000066735.V335159.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Accommodation is provided over two floors and a passenger lift is available. An enclosed and beautifully maintained garden is provided at the rear of the property. A full tour of home was undertaken and many improvements have taken place since the last inspection to provide people with a more homely place to live. People who use the service have actively been involved in choosing the décor and redecorating the lounge/dining room and vacant bedroom. New high quality furniture and soft furnishings have been purchased and it is clearly evident that people are very satisfied with their home. Bedrooms are personalised and reflect individuality and the ground floor shower room has recently been refurbished providing people with a much30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 18 improved facility. It was reported that the fire officer or Environmental Health Department have not visited since the last inspection. The home was found clean and tidy and a cleaning schedule is included on the staff handover sheet. Staff spoken with stated that people are encouraged to maintain a clean environment as much as possible as evidenced during the inspection. Substances hazardous to health were found appropriately stored and a designated member of staff has recently been allocated responsibility for this area. It was reported that several staff have undertaken a distance learning course in the control of infection and contamination and others have recently attended a short training session provided by Shropshire Partners in Care, who the home are members. 30 Keepers Crescent DS0000066735.V335159.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): 32,33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are trained, skilled and in sufficient numbers to support the needs of the people who use the service. People are safeguarded by the homes recruitment procedures and help to choose the staff they wish to support them. EVIDENCE: Observations made throughout the inspection clearly evidence that people who us the service are supported by a committed staff team who have an excellent understanding of their individual needs. Staff communicated with service users appropriately and have developed positive working relationships with the people they support. Staffing levels reflect the needs of the people accommodated and rotas have recently been changed to provide greater flexibility to fit around the lifestyles of service users. It was reported that the home is fully staffed and the use of agency staff is minimal. A comprehensive induction pack has been developed to support agency staff at the home. One staff member stated ‘Agency staff 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 20 are treated no differently to permanent staff and we ensure they read support plans prior to working directly with people we support’. Feedback received from four staff on duty was extremely positive. Staff have recently been allocated designated areas of responsibility such as training, health and safety, medication, staff rota’s etc and discussions held indicated that this is proving successful and empowering the staff. Staff on duty reported that they are provided with good training opportunities as evidenced in certificates seen and confirmed that they are in receipt of formal supervision. Comments received include: ‘The team functions well and we advocate very much for the people we support. We are not far from doing it right’. ‘Things are brilliant…we are very good staff team and get on well. I enjoy coming to work. The home is one of best homes I could ask to work in’. ‘Not a day I ever dread coming to work, it’s a lovely home with a good team and I really enjoy working here’. Recruitment procedures and personnel files for two staff recruited since July 2006 were examined during the morning of 23rd April 2007. No shortfalls in documentation required by Regulations were identified however the need to ensure appropriate referees was discussed with the acting area manager. Dimensions have requested to centralise their Human Resources records, which CSCI policy now allows following approval. This allows the provider to keep the originals of their records centrally and keep a proforma in the care service, which the acting area manager committed to undertake. One person was involved in the selection of two new staff and appeared to enjoy his role in this process. Individual training records examined and discussions held evidence that staff have been provided with good training opportunities. It was reported that all but two staff have completed their National Vocational Qualification (NVQ) award. A staff member stated ‘Training is readily available and undertaken to improve the service provision but we would like autism and sign language which is being sourced”. Staff spoken with confirmed that they are in receipt of formal supervision as evidenced on the supervision and joint performance review tracker form. 30 Keepers Crescent DS0000066735.V335159.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): 37,38,39,41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ethos of the home is based on openness and respect with aspects of performance regularly reviewed to achieve good outcomes for the people who use the service. The home is well managed and maintained, which ensures the safety of service users and staff. EVIDENCE: The home is managed by Mr Daniel Frater who has recently been registered with CSCI. Mr Frater has attended numerous training courses since joining the organisation and is currently undertaking management qualifications appropriate to his role. Staff spoken with stated that the manager is approachable and supportive. Discussions held with the manager evidenced 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 22 that he has made several changes since his appointment and plans to develop the service further in conjunction with service users and his staff team. Since the last inspection a number of groups have been developed across the organisation to include a Regional Advisory forum and Joint Consultancy Group involving people who use services and staff to assist with quality assurance and future planning. It was reported that quality assurance surveys are currently being devised and will then be distributed to service users/ their representatives, families and stakeholders. A family event was held in Telford in December and a fun day has been arranged for June. Reports of visits required under Regulation 26 are readily available and the team have recently developed a service ‘PATH’ for the forthcoming year to inform planning and review, which is comprehensive. Positive feedback was received by CSCI in preparation for this inspection and comments have been included in the summary section of this report. Records examined during the inspection were readily accessible and presented to a high standard and there was evidence that staff are requested to sign documentation to confirm that they have read this. Health and safety procedures appeared satisfactory at the time of the inspection and all staff spoken with confirmed that procedures safeguard both service users and staff. One staff member now has designated responsibility for matters pertaining to health and safety. Records examined evidence that health and safety checks are carried out at the required frequency and all equipment serviced within required timescales. Staff receive training in safe working practices as confirmed by records examined and discussions held with staff on duty. 30 Keepers Crescent DS0000066735.V335159.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 3 2 x 3 x 4 x 5 3 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 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 x 3 3 x 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 24 NO 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 A comprehensive policy and procedures document must be developed for the handling of medication within the home, which depicts all of the procedures that are, and need to be, carried out by the care staff to ensure people are safeguarded. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations It is recommended that staff competency to handle and administer medication to people who use this service is checked on a regular basis so that medication is given correctly at all times. 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 30 Keepers Crescent DS0000066735.V335159.R01.S.doc Version 5.2 Page 26 - 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!