Inspection on 16/11/06 for 35 Worth Crescent

This inspection was carried out on 16th November 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 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

35 Worth Crescent 18/01/06

35 Worth Crescent 25/07/05

35 Worth Crescent 18/02/05

35 Worth Crescent 26/08/04

35 Worth Crescent 10/06/04

35 Worth Crescent 18/02/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Worth Crescent, 35 35 Worth Crescent Stourport on Severn Worcs DY13 8RR Lead Inspector Dianne Thompson Unannounced Inspection 16th and 21 November 2006 13:00 st Worth Crescent, 35 DS0000037501.V317290.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 Worth Crescent, 35 DS0000037501.V317290.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. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Worth Crescent, 35 Address 35 Worth Crescent Stourport on Severn Worcs DY13 8RR 01299 822515 01299 829087 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.worcestershire.gov.uk Worcestershire County Council Miss Tanveer Zahra Shah Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate people for short-term care only. The home may provide day and evening care for up to five additional persons at any time. The home may accommodate service users who have an additional physical disability, sensory impairment or mental disorder. Date of last inspection Brief Description of the Service: The home is a large, detached building located in a residential area on the outskirts of Stourport -on-Severn. Accommodation is provided on two floors and service users are accommodated in single bedrooms. The home does not have a lift. However, service users who have mobility problems or require the use of a wheelchair can be accommodated in the two single bedrooms on the ground floor. The home has ramped access at the front entrance and ramped access to the rear garden. Worcestershire County Council operates the home and the Responsible Individual is Amanda Nally. The registered manager is Miss Tanveer Shah. The main purpose of the home is to provide a respite/short stay service for younger adults with mild to moderate learning disabilities. Some of the service users may also have physical disabilities or mental health problems. The home is able to provide accommodation and care for a maximum of ten service users or guests. In addition, the home is also able to provide day and evening care for a further five people at any given time. The fees for staying at Worth Crescent are currently £9.00 per night. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that included an unannounced visit to Worth Crescent. A second visit was arranged so the manager could be available to discuss the development of the service. The main purpose of this inspection was to learn how the service is developing. Service user and staff records were examined, and a tour of the building was also carried out. Information from reports of monthly visits by the provider’s representative was used to inform this report. There are 42 people who use the service at Worth Cresent. They stay overnight during the week and for week-ends. On this occasion three service users were staying at the home. Time was spent with service users and staff. What the service does well: Worth Crescent looks after people for planned short stays to give their families a break. The home is kept bright, clean and safe. It has a relaxed and welcoming atmosphere. The home looks after people well and staff get to know everyone so they know what care is needed. The home gives clear information to service users. This helps service users choose whether they would like to stay at the home. Information is written in care plans. These plans tell staff what help people need. Staff look after medicines safely. The home trains staff to give medicines and keep people safe. Staff support service users if they have any concerns. The home checks all staff before they start to work in the home to protect service users. The home is managed with an open and positive approach. Worcestershire County Council makes sure the service develops in the way service users want. They check that the home is a safe place to live and work in. Worth Crescent, 35 DS0000037501.V317290.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. Worth Crescent, 35 DS0000037501.V317290.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 Worth Crescent, 35 DS0000037501.V317290.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, 2, 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable information is available to help service users choose whether they would like to stay at Worth Crescent and whether the service will meet their needs. A full assessment and introductory visits are completed for all prospective service users. EVIDENCE: The home has information about the service for prospective service users and their families. The manager said that copies of the Statement of Purpose and Service User Guide are accessible to all, including visitors to the home. All service users will receive copies of relevant information during their introduction to the home, and will be offered in preferred formats, such as symbols and pictures. Admission procedures and assessment forms are evident for those service user files examined. An admissions policy and procedure is in place. An assessment completed for a service user recently admitted to the Service demonstrates that the home obtains information about prospective service users, their Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 9 background, their needs, their likes and dislikes when they are referred for a placement. Information is gathered from a range of sources including other relevant professionals, visits to homes or schools, and discussions with family members. The home however, does need to make sure that all information is obtained when emergency admissions occur. An emergency admission had been made to the home but sufficient information was not available at the time of the inspection visit. The home has a statement of terms and conditions for staying at the home that service users and their families sign. Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about users assessed needs. They include risk assessments on how risks are to be reduced and independence promoted. Service users are enabled to make choices and decisions in their daily lives and routines. EVIDENCE: The home provides a good standard of care for all service users, which has developed through getting to know individuals and how to respond to their needs. Three service users were at home at the time of the visit and said that they liked the home and the staff. Files for two service users, one of whom was an emergency admission, were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 11 The requirement from the previous inspection that new service user plans, covering Standards 2.3, 6-21 must be completed and introduced for the service users that stay regularly has not been met. This was discussed with the registered manager who said that a senior member of staff has been nominated to upgrade all service user files. The files contained information that was confusing, duplicated or out of date. This was discussed with the registered manager who was advised that service user files must be completed, as a priority to make sure all relevant information is available to promote consistency of care. This will also meet the legal requirement. The manager intends for the new service user format to be used to improve consistency and link in with day services and share guidelines and risk assessments. It was apparent from observations and discussion with the staff on duty that they knew the service users well and how to meet their needs. This included the support provided for one person who had been admitted to the home as an emergency placement. It is essential however, that where emergency admissions occur there is sufficient information to provide care and support which meets service users needs. Staff should have information about likes and dislikes, preferred routines and activities available so they can provide the appropriate support at all times. Each service user is allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs. Risk assessments are completed for all individuals. Risk assessments, which are no longer relevant however, should be removed from the current working file. Risk assessments are carried out where service users need support during the night. These risk assessments also include an action plan in the event of an emergency. This action plan is available for all staff on duty, and includes a mobile phone and contact numbers for support Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users receive help and encouragement to take part in activities and are supported to access facilities within the wider community. The home offers a flexible menu and promotes a healthy diet for the welfare of all service users. EVIDENCE: Service users usually stay at the home for evenings, weekends or holiday stays. At the time of the inspection visit three service users were having their lunch. They spent some time after lunch relaxing in the lounge. During the week service users come to the home for overnight stays, and there is less time available to organise outings or activities. Time is usually taken up with personal care, preparation and eating the evening meal. There is music, videos and television to watch or listen to. All service users are Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 13 encouraged to be involved in the home’s daily routines during their stay, for example, being involved in the cleaning of bedrooms to their ability. Activities also include looking at books and magazines, puzzles, art and crafts. Staff said there is more time available at weekends for activities such as the cinema, shopping, bowling, and meals out. The home does not have its own transport, but promotes alternative means such as public transport, taxis or hiring a vehicle where costs can be shared. On service user said they like to go to the shops to buy books, another said they wanted to go to the shops to buy some toiletries. Service users told of their visit to the cinema on Saturday night to see a Michael Caine film, which they said they enjoyed. Another service user said they like to watch the television, but ‘don’t like watching westerns’. Through discussion and observation it is obvious that the service users continue to have opportunities to participate in a variety of activities in and out of the home and that personal development is encouraged. The home needs to develop a system where all activities are recorded to demonstrate the lifestyle available to people using the service at Worth Crescent. A staff meeting was held following the inspection visit and recording activities was discussed and agreed. The manager also confirmed that a diary for 2007 had been purchased so that a programme of planned activities can be organised. Service users are provided with a varied, healthy and nutritious diet, taking into consideration any dietary needs, likes and dislikes. A record of food provided is kept for each service user staying at the home. Drinks are freely available. Food shopping had not been possible on the day of the inspection visit and staff arranged the evening meal using food that was available, which was limited. A discussion took place with the manager about a contingency plan should a similar situation happen. The manager has discussed this with the staff team to ensure that adequate food is available at all times. Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are identified in care plans. The plans provide information to give support for all service users in a way that they prefer. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of service users and staff. EVIDENCE: Service users’ care records and plans provide information about the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about service users preferred personal care routines. An admission form is now completed for each occasion a service user stays at the home to make sure that the home has up to date information about each persons situation, particularly in relation to their health and medication. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 15 Staff said they are able to communicate with service users verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Staff on duty and the manager said that all personal care is given in private to promote dignity for all service users. One service user is relatively new to the home and the staff commented on how well he has settled into the environment. Service users health and well-being is monitored during their stay at the home. Health action plans are being completed for most service users by their day centres, and the home is linking with the day centres to improve information sharing and consistency. Staff have received training in diabetes and in testing for blood sugars from the community nurse as recommended at the previous inspection. Service users and the home are supported by emergency medical services, which includes the local GP surgery, as service users have established medical support arrangements from their own homes. The home has a medication policy and procedure in place. Medicines are suitably and safely stored and there is appropriate storage for controlled drugs, should they be required. The administration of medication was observed. Two members of staff completed this. Medication was dispensed into individual pots and name labels were attached to ensure medication is given to the correct person. Once the medication had been given to the right person both staff members signed the medication record sheet. Medication records were checked and all was satisfactory. The manager confirmed that the organisations policies and procedures would be followed should any medication error occur. Additionally these would be reported to CSCI. Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s complaints procedure that is available, with appropriate information for staff provided. Staff support service users to express their views and any concerns they may have. EVIDENCE: The home has a Compliments and Complaints folder. No complaints have been made to CSCI since the previous inspection. The home has received both compliments and complaints. The complaints log was seen and it was evident that complaints made to the home had been satisfactorily resolved. Complaints are now logged individually to respect the confidentiality of the service user and the complainant. Service users and their families should now be assured by the inclusion of an appropriate statement in the revised complaints procedure and in the service users’ guide, that they will not be victimised for making a complaint. The home has procedures in place for the protection of vulnerable adults. Worcestershire County Guidelines on abuse and a copy of the Department of Health ‘No Secrets’ guidelines are available in the office. Service user’s money is checked into the home by two staff members and returned to the service user at the end of their stay. Staff sign the individual record sheets for each transaction and service users are now being supported to keep their own money in a lockable place in their bedroom. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 17 The records kept of all the service users incoming and outgoing finances and payments are now independently monitored and audited on an annual basis. The last audit was December 05 and this year’s audit is due. This meets the recommendation of the previous inspection. A policy has been developed and implemented regarding service users’ money and financial affairs, which ensures service users’ access to their personal financial records, safe storage of money and valuables, consultation on finances in private, and preclude staff involvement in assisting in the making of or benefiting from service users’ wills. Further information has also been included in care plans with a laminated copy of the procedure in the staff office. Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Worth Crescent Service provides accommodation for service users that meets their needs and offers a spacious and comfortable stay away from their home. The home is kept clean which ensures that good hygiene and infection control is maintained for the benefit of service users. EVIDENCE: The home is warm, clean and tidy. A tour of the home was completed and all bedrooms were seen. All bedrooms are single and suitably furnished and decorated. The home has adequate shared living space with improved bathroom and toilet facilities. Service users can choose either shower or bathing options. The home uses photographs on the bedroom doors to indicate who is staying in which room. This helps service users to identify their rooms. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 19 The upgrading of the two bedrooms, staff facilities and bathrooms, toilets and laundry facilities has been approved by the relevant agencies. Copies of the relevant approval documents have been supplied to CSCI. The laundry room is now used solely as a laundry and staff are now allocated a separate office on the ground floor. The refurbishment of the kitchen is being planned, but as yet the management of this refurbishment has not been fully established. Some areas of the home have been redecorated. For example the hall has been repainted but the walls have been left bare. This makes the home feel impersonal. Curtains or a blind is needed to the window on the stairs. The lack of ‘homely touches’ such as pictures on the bare walls was discussed with the manager. Following the inspection visit, the manager confirmed that pictures have now been purchased and efforts are being made to make the house more homely. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available and there are suitable arrangements in place for the disposal of clinical waste. Aspects of infection control identified in the audit and at the previous inspection have now been improved, with training completed and a designated person responsible for monitoring infection control in the home. Worth Crescent, 35 DS0000037501.V317290.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Suitable staffing levels are being maintained, and relevant training is being arranged so staff are able to meet service users’ needs. The staff team understand their responsibilities and are committed to their role. They are well supported and work together to provide service users with consistent and quality care. The home’s recruitment policy and practices make sure that suitable staff are employed and that all necessary checks are made to ensure the safety of all service users. EVIDENCE: The manager said that the staffing situation is becoming more settled now. Recent successful recruitment of staff will provide a full staff team at the home. A copy of the rota was seen and this indicates that sufficient staff are on duty when service users are staying. This usually means a minimum of three staff. At night there are two members of staff on the premises, one of Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 21 whom may be a waking member of staff if service users need assistance during the night. WCC operates a full training programme and access to more specialist courses relevant to the home will be provided. This will include MAPPA, Autism and Sensory Impairment. The training programme was seen and evidence is available to show training that has been completed and planned for the forthcoming year. Equality and Diversity was completed in October 06, Infection Control and Manual Handling during December 06, with training planned for Food Hygiene and First Aid in January 07. Other training completed includes Abuse Awareness, Challenging Behaviour, Dementia, Sensory Awareness, Sexuality and Communication. Seven staff have completed LDAF Induction and Foundation training. Fire training is completed on a cyclical basis. The proposed training programme is now being implemented to make sure that staff receive training in NVQ in care, safe working practices and caring for service users with special needs. Five staff are currently registered and working to complete NVQ level 3. One member of staff has completed their NVQ, and the newly appointed staff have been recruited with current NVQ qualifications. The homes administrator has an NVQ qualification. Seven out ten members of the staff team are currently qualified to NVQ level. This meets 50 of care staff to achieve a care NVQ as required by the National Minimum Standards. Further training is planned to make sure this level is maintained. Staff training discussion is included in staff supervision and appraisals. Training is also discussed in team meetings. Information is made available and requests for specific training can be made. Evidence was seen where the management team provides regular supervision. Staff meetings are held regularly. Staff spoken to confirmed that they felt supported and enjoy working at the home. Team building sessions involving the manager and all staff have not yet been held, although there has been one day together that was spent looking at equality and diversity. The manager is looking to plan team-building sessions when the newly recruited staff commence their employment so they can be part of the team building process. The home has appropriate recruitment policies and procedures in place. The manager confirmed that all prospective staff complete an application form. References are obtained, including one from their most recent employer. Copies of proof of identity and documentation for all candidates are taken at interview. An enhanced CRB/POVA (police) check is undertaken before their appointment is confirmed. All staff are required to work a six-month Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 22 probationary period at the home. Evidence was seen of CRB and photo identification that was being processed for newly appointed members of staff. There is now an In-house Induction for all new staff that is recorded on the home’s induction checklist. This meets the recommendation of the previous inspection. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed with an open and positive approach. Worcestershire County Council monitors the home in various ways to ensure that the service continues to develop as service users want and that the home remains a safe place to live and work in. EVIDENCE: The registered manager, Miss Tanveer Shah has many years experience in residential care. Miss Shah says she operates an open door management style. She has undertaken a wide range of other training relevant to service users’ needs. It is evident she is knowledgeable about learning disabilities and the implications for service users themselves and their care. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 24 Management responsibilities in the home are shared with a deputy manager and two seniors. They are involved in organising the running of the home, health and safety promotion, staff supervision and induction. An administrator also supports the home. Staff confirmed the manager is approachable. They say the staff team works closely together to help service users enjoy their stay and to make sure that all their needs are met. In respect of management support from the provider, WCC has Training and Human Resource Officers who are available to advise and support the home. The provider’s monthly visits are one of the ways that WCC monitors the service and how the home is being run. These visits include interviews with staff and service users and an audit of relevant aspects of the service, including records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. A quality assurance programme has been introduced to the service by WCC. The audit has been completed and a review of the findings is to be conducted. There are systems in place to maintain the health and safety of the service users and staff such as risk assessments for safe working practices and the accident book. Fire signage has now been installed on the first floor of the home. The home’s fire risk assessment has now been completed and is available in the home. Worth Crescent, 35 DS0000037501.V317290.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 3 4 X 5 X 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 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 3 X X 3 X Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement The registered manager must make sure that all relevant information is obtained when emergency admissions occur. The new service user plans, covering Standards 2.3, 6-21 must be completed and introduced for the service users that stay regularly. For other service users, prior to their next admission. (Previous requirement not met) Timescale for action 31/12/06 1. YA6 15 31/03/07 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 YA19 Good Practice Recommendations Respite service users would benefit from having health action plans. Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Worth Crescent, 35 DS0000037501.V317290.R01.S.doc Version 5.2 Page 28 - 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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