Inspection on 25/07/05 for 35 Worth Crescent

This inspection was carried out on 25th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

35 Worth Crescent 16/11/06

35 Worth Crescent 18/01/06

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 Worcestershire DY13 844 Lead Inspector Penny Wells Unannounced 25 July 2005 16:45 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 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 Stationary 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 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Worth Crescent, 35 Address 35 Worth Crescent Stourport on Severn Worcestershire DY13 8RR 01299 822515 01299 829087 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Worcestershire County Council Care Home 10 Category(ies) of LD Learning Disability - 10 registration, with number of places Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: In addition to those referred to on the previous page, the following condition applies: 1. The home may accommodate people for short term care only 2. The home may provide day and evening care for up to five additional persons at any time. Date of last inspection 18 February 2005 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. The home is operated by Worcestershire County Council and the Responsible Individual is Stephen Chandler. The home has been without a registered manager since 2003. 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 user or ‘guests’. In addition, the home is also able to provide day and evening care for a further five people at any given time. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home and there had been visits to the home on 20th April, 6th & 10th May 2005. On 20th April the pharmacist inspector viewed the medication system and on 10th May a second inspector, D Thompson was present. The visits in May focused on the management and staffing arrangements, which had previously been of concern. Reports of these visits have been sent to the responsible individual and deputy (in the absence of a manger) in letter format and are available from the home or CSCI, on request. For this visit, two hours was spent in the home and time preparing and reading information about the home. On this occasion the alterations to the premises were viewed. All the visits took place late afternoon so that the inspector(s) could meet with the service users staying for the evening and overnight. The home was offering care and support packages to 50 service users and there were three prospective users. At these visits there were up to 10 persons using the service. The co-operation and time service users, the deputy and staff gave the inspector was appreciated. What the service does well: Maintains a welcoming, relaxed and friendly atmosphere for the service users using the home for short stays. This atmosphere has been commendably sustained by the deputy and staff, in the absence of a manager, and during staffing difficulties. The service users all said how much they enjoy visiting 35 Worth Crescent and in particular liked the outings and food. When staffing levels permit, activities are arranged in and out of the home at weekends and evenings. For example at this visit all the service users were having a choice of cooked meals or salad before going out to the cinema. The home is always clean, safe, bright and well maintained with comfortable single bedrooms offered to each person. The permanent and relief staff are experienced and the majority know the service users well. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Ensure that all the above are in place by 30th September 2005. The Statement of Purpose and Service User Guide are updated, introduced and given to the service users and their representatives. Also a contract needs to be introduced. Review the service user plans and risk assessments. This is to ensure there is detailed information about the needs of each individual who comes to stay in the home so that staff can offer them consistent care and promote their independence. Staff have opportunities to obtain NVQ qualifications in care and training in managing challenging behaviour. The new staff group may need time to get to know each other and the aim of service, through a series of team building meetings. The manager needs to apply to CSCI for registration. The provider needs to send CSCI an updated statement of purpose, which indicates that the service can provide for users who may have a physical disability or mental health problem, as well as a learning disability. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 7 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. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-5 Information about the home should be updated and circulated to the service users and their representatives. Service users are given opportunities to visit the home before coming to stay on a regular basis. The home should complete it’s own detailed assessment prior to admission to ensure that the service can meet the individual’s needs. EVIDENCE: The statement of purpose and draft service user guide need to be updated, agreed with the new manager and then introduced and given to the service users and their representatives. Copies of the updated documents need to be sent to CSCI. These documents should include a statement about the maximum time a service user can stay at this respite home. It is not appropriate for the service to be used for a service user who is homeless unless there is a plan, at the time of admission, for the service user to move on within a given time scale, to an identified place (see Standard 6). Also copies of these documents must be sent to CSCI. A draft contract has been circulated by a sister home and could be amended to apply to this respite service. The home were considering prospective service users and ensuring that they had introductory visits to the home. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 10 The home has it’s own assessment form but usually relied on the community care assessment, compiled by a social worker, and information from the short term break panel. (This panel consider who should be referred to 35 Worth Crescent for respite care). The home should complete their own detailed, written assessment to confirm that the service can met the needs of the person, especially as the service is being requested to consider prospective service users who have more complex needs, including challenging behaviour. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 The service users’ individual plans needed to be developed, especially if the person has complex or changing needs. Also individual risk assessments and restraint procedures, must be in place, if needed. The service users were making decisions about their daily routines and being respected and supported appropriately by staff, in making these decisions. EVIDENCE: All the service users now have a care and support plan which had been reviewed earlier this year. However the deputy and inspector both considered the plans needed to be developed, as the plans were brief especially for those with complex or changing needs. The plans needed to be updated, with the service users, especially when a person’s situation has changed, to ensure care and support is offered in a consistent manner. Also the plans needed to be developed to include goals and promoting independence. Observations and discussion with service users and staff indicated that service users are offered appropriate care and support according to their individual situations but this is not always reflected in the written plan. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 12 Two service users who sometimes had challenging behaviours were discussed and one plan viewed. It did not give a detailed picture of the situation and the support that staff were giving. However it was reassuring that verbally the deputy had obtained, for both these service users, up to date pictures of their needs from day placements and health care professionals. Distraction techniques were known and guidance being obtained from health care professionals and day placements. Risk assessments were in place for service users. For a few service users there may need to be individual restraint procedures in place but these were not available (see Standards 19 & 23) although reference was made to a procedure in the plan viewed. A service user was again staying at the home for an unspecified time whilst an alternative permanent home was being found. This person had already been at 35 Worth Crescent for ten weeks and confirmed she was settled but it cannot become a permanent placement. At all three visits service users were observed making decisions about their routines and being consulted by staff in a courteous and helpful manner about their wishes with regard drinks, meals and activities. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-17 Service users are able to continue with their own routines and/or participate in a variety of activities in and out of the home, respected and supported by staff. Service users are offered a variety of food and drinks, taking into consideration healthy eating and individuals’ dietary needs and preferences. EVIDENCE: The service users confirmed that they enjoyed staying at 35 Worth Crescent where there was a variety of activities, in and out of the home, and they were able to continue attending their weekday placements. All the service users had placements at day centres, colleges, work experience during the week and the home did not routinely offer day care unless a day placement was closed or a service user was unwell. The inspector had observed that on such days there were sufficient staff on duty during the day to support the service users in activities, in and out of the home. Service users regularly go out in ones or twos with staff to the shops, to choose a video or for a walk and this was observed at the previous visits. At this visit the eight service users were having an early meal and keen to going to the cinema with four staff. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 14 Service users liked going out in the summer evenings to the pub, walking, to the cinema and ‘night out’ club. Staff find out about community events and clubs that service users could attend such as a music club and forest flyers. The home would benefit from an unmarked mini bus or people carrier(s) rather than staff having to transport service users in their own cars. Service users can, and are encouraged to keep in contact with their families and friends whilst staying. Service users are reassured by staff about their families’ whereabouts whilst they are away from their permanent home. The home now has an arrangement for giving the service users keys to their bedrooms, if they so wish, and a log is kept to check keys are handed in before a service user leaves. Service users own routines and personal space are respected. The evening meal is a highlight of a stay, with many of the service users commenting that the food was nice and they had a choice of food and drinks. A home cooked meal with fresh vegetables is prepared each evening and there is a vegetarian option, and other alternatives, if a service user does not like the two dishes planned. A record of food provided and eaten by each person is kept. Menus are not available but the staff plan the main meals and shopping on a daily basis, according to which service users are staying (taking into consideration any special diets, the service users likes and dislikes). The meals observed have always been varied, nutritious, and appetizing. The home’s aim is to ensure that the service users eat and enjoy their meals during their stays. A list of the meals served could be compiled to show prospective service users and their families. A variety of hot and cold drinks are available at any time, with service users being welcomed into the home of an afternoon with drinks. Some service users are able to make their own drinks. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 The service users well and both their personal and health care needs were being met. The health care records needed more detail. EVIDENCE: Service users who needed assistance with their personal care were supported, in private, by staff of their choice and gender. The majority of service users just needed prompts from staff. The health care needs of service users were recorded in their plans but often not in detail or up to date, as the home were relying on families/carers to provide this information. At this visit the service users were physically well and those who had emotional problems were being appropriately supported. The home had a form for the families/carers to complete for admission but the details varied and sometimes a service user would arrive without a form. It was recommended that the dose and strength of medication be included on the form. It was said that medication does not always arrive in the original containers with the pharmacist’s label, which has been previously recommended. Also the Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 16 deputy was reminded that if a medicine label indicates ’as directed’, the prescribing doctor should be contacted to confirm the dose. Health Action plans would be most beneficial to this respite service, if fully completed and up to date. The plan for a recent admission was viewed and the health care information not detailed but the deputy had consulted with health care professionals regarding the service user’s emotional and mental health needs. The pharmacist inspector had visited the home to view the medication system on 20th April 2005 and considered there had been a positive move towards good control and handling of medication in the home. The visit was made following the reporting of a medication error and the inspector considered the incident had been dealt with appropriately. The requirements and recommendations relating to the medication system were outlined in her letter to the home. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home should have procedures in place for managing challenging behaviour and safeguarding service users and staff. Staff should have the relevant training to support service users who display challenging behaviours. EVIDENCE: Aspects of these two standards were discussed but the standards were not fully assessed, hence have not been scored. There had been no complaints since the last inspection when this standard was met. Two of the current service users, on occasions, demonstrated challenging behaviour but the home did not have a policy and procedure on restraint (it had not been considered necessary previously) nor individual restraint procedures for the current service users. Only a few staff had received training in challenging behaviour, and management of actual and potential aggression (MAPA). If the service is now accepting service users with challenging behaviour (or service users whose behaviours have deteriorated), all staff need to have the relevant training with a policy on restraint and individual restraint procedures available in the home. To advise staff to call the SS emergency duty team should a crisis arise, is not adequate and would not safeguard service users and staff at the time of an incident. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 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 standard(s) 24-30 The premises are suitable, homely and safe for the service users. The alterations taking place will improve the facilities for service users and staff. EVIDENCE: A full premises inspection took place on 26.08.04 and was followed up on 18.02.05, so on this occasion the inspector viewed only the rooms that were being upgraded. See previous reports for details. It was pleasing to see that the alterations, previously agreed, were well underway and not unduly affecting the service users. The scoring reflects that alterations are taking place and that not all the rooms are in use. When the alterations are completed and rooms furnished, all these standards will be met. The home continued to be accessible, bright, safe, clean and furnished in a comfortable and homely way. The ground floor was suitable for service users with mobility problems. There is a lounge and dining room. The home has an extensive back garden and patio area. On the ground floor an en suite facility with toilet, washbasin and shower was being installed in one of the two single bedrooms. The specialist bathroom had Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 19 reduced in size but was still most accessible. A separate toilet had been enlarged to give better access and a shower room with toilet was to be upgraded. The shower had been repaired since the last inspection and service users liked having this showering facility. It is hoped that it can be replaced with a walk in shower so it is suitable for service users with mobility problems. On the first floor two new bedrooms of an acceptable size were being completed. One of these bedrooms will have an en suite facility. The two undersized bedrooms will become offices for the manger and administration so the office on the ground floor can become a staff room. None of six bedrooms on this floor needed upgrading and the sample viewed were suitably furnished and had a call bell. However it was of concern that in some of the bedrooms the window restrictors were not being used (see Standard 42). Also on the first floor, a staff shower room and additional bathroom were near completion. The shower room, two separate toilets and a bathroom for service users were to be upgraded. Discussion took place about the poor access into the separate toilet, next to the bathroom, and it was agreed that this toilet should be incorporated into the adjoining bathroom, which would give better access to both facilities. On the ground floor, the current staff room/laundry will become a separate laundry. These alterations are welcomed and will give the service users and staff improved facilities. It was also being proposed that the communal areas of the home would be decorated and new windows fitted. On completion of the building work, a building control completion certificate, certificate of electrical safety (carried out by an industry accredited engineer) and commissioning certificates for any new call bells, smoke detectors etc need to be obtained, retained in the home and copies sent to the CSCI, prior to the altered rooms being used. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Service users were being supported by staff who are experienced, committed and clear about their roles. The home will soon be fully staffed including a manager and senior team. EVIDENCE: At this visit the inspector was advised that the manger was commencing on 8th August 2005. The deputy and one senior had been appointed and were in post. The second senior support worker would be joining the team later in August. The home now had a full compliment of support workers and agency staff were no longer being used. There was a bank of experienced, relief staff who continue, at the moment, to cover some shifts. This was welcomed and a vast improvement in the staffing situation at the last, full inspection in February 2005. The staff are experienced and have the knowledge and skills to support service users with learning disabilities. Many of the staff know the service users well, having worked with them either in this home or in their day placements. The home have rotas, which indicate the number of staff on each shift according to the number and needs of the service users using the service. A senior on each shift is now clearly indicated on the rota. Also the night Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 21 arrangements – there are two staff in the home, one of whom may be awake if service user(s) are likely to need assistance at night. The staff were continuing to attend training for NVQ’s in care, protection of vulnerable adults, infection control and fire awareness. Including the relief staff, 50 of the staff have an NVQ in care level 2 or above. Training sessions in autism and communication were planned. The deputy and staff are to be commended on keeping the service going for the service users this year. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42,43 The service was being managed appropriately, in an open manner with service users being considered foremost. The window restrictors must be in place when service users are at home. EVIDENCE: The manager’s post was to be filled on 8th August. The service manager has been visiting regularly and submitting reports to the County Council and CSCI. The home has run smoothly under the leadership of the acting deputy (now appointed permanent deputy) who has been at the home for just six months. The standard on Safe Working Practices is wide ranging and could not be fully assessed and discussed with the staff (they were taking the service users to the cinema) on this occasion. However the following was noted: • Some staff had attended courses on protecting vulnerable adults. • Most staff were first aiders Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 23 • • • • • The deputy had been on a fire warden course and in house fire training for staff was taking place. A member of staff took responsibility for COSHH and infection control and would be cascading the training to staff. The window restrictors were unclipped so that the windows could be opened widely to air the bedrooms during the day when service users are out and some were still wide open on the first floor when the service users came home. The window restrictors need to be clipped into place before the service users return to the home and in place at all times they are in the home. The fire risk assessment will need updating when the alterations in the home are completed. A keypad had been fitted to the kitchen door to ensure the door remains closed unless staff are present. It was not connected to the fire alarm system but was not thought to be a fire exit route. This should be checked with a Fire Safety Officer. Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 2 3 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 2 2 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Worth Crescent, 35 Score 3 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5,6 Requirement A service users’ guide, that includes all the information detailed in Regulation 5 and Standard 1, must be available in the home and copies must be given to all current, and any prospective, service users and their families with a copy sent to CSCI. (timescale of 30.04.05 partially met) A statement of purpose, that includes all the information detailed in Regulation 4, Schedule 1 and Standard 1, must be available in the home and a copy must be sent to CSCI. A written assessment must be completed before the admission of any service user and in accordance with the requirements of Regulation 14 and Standard 2. or a detailed, up to date assessment obtained from the placing social worker. (previous timescale partially met) The contract/statement of terms and conditions must be drawn up so that it includes all the information detailed in Standard E52 S37501 Worth Crescent V241146 250705.doc Timescale for action 30.09.05 2. 1 4,6 31.08.05 3. 2 14 For the next new admission and on going 4. 5 5 31.10.05 Worth Crescent, 35 Version 1.40 Page 26 5. 6-21 15 6. 24-30 24 7. 43,1 4,6 8. 9. 42 13 10. 34 19 11. 39 24 12. 40 12 5.2 and a copy issued to each service user and/or their relative. (timescale of 31.05.05 partially met) The service user plans must contain detailed information about the individual’s needs, healthcare and treatments. (timescale of 31.05.05 partially met) The upgrading of the two bedroms, staff facilites and bathrooms, toilets and laundry facilities must be completed and approved by the relevant agencies. The County Council must arrange for the statement of purpose to be updated and reflect the the home provides care to service users with a physical disability or mental health problems. (previous timescale of 31.03.05 partially met) Window restrictors must be in use at all times when service users are in the home. The following requirements were not assessed on this occasion and will be assessed at the next inspection with the new manager: The staff files in the home must include the information outlined in Schedule 2 & 4. (previous timescale 31.05.05) A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 39. (previous timescale 31.05.05) The home’s written policies must comply with current legislation and recognised professional standards and cover the topics set out in Appendix 2 of the National Minimum Standards. E52 S37501 Worth Crescent V241146 250705.doc 31.10.05 30.09.05 31.08.05 Immediate and on going 31.10.05 31.10.05 31.10.05 Worth Crescent, 35 Version 1.40 Page 27 (previous timescale 31.05.05) 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. Refer to Standard 2 5 6 Good Practice Recommendations The good practice outlined in National Minimum Standards relating to admissions should be implemented. The contract/statement of terms and conditions should be in a format appropriate to the service users’ needs. Service user plans must be in a format, which the service user can understand and be held by the service user unless there are, clear (and recorded) reasons not to do so. The records kept of all the service users’ incoming and outgoing finances/payments should be independently audited/monitored. Service users and their families should be assured, preferably by the inclusion of an appropriate statement in the complaints procedure and in the service users’ guide, that they will not be victimised for making a complaint. A policy should be developed and implemented regarding service users’ money and financial affairs, ensuring 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. Team building sessions involving the manager and all the staff should be held, led by an external facilitator. In-house Induction for all new staff should be recorded.(not assessed on this occasion). Consideration should be given to the home having a mini bus or people carier(s) to take the service users out. 4. 5. 7,23 22 6. 23 7. 8. 9. 33 34 12-16 Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 Page 28 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road Worcester WR3 7NW 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 Worth Crescent, 35 E52 S37501 Worth Crescent V241146 250705.doc Version 1.40 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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