Inspection on 06/06/06 for 65 Gloucester Crescent

This inspection was carried out on 6th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

65 Gloucester Crescent 16/10/07

65 Gloucester Crescent 08/03/07

65 Gloucester Crescent 23/08/05

65 Gloucester Crescent 18/04/05

65 Gloucester Crescent 12/11/04

65 Gloucester Crescent 15/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Gloucester Crescent (65) 65 Gloucester Crescent Laleham Middlesex TW18 1PN Lead Inspector Damian Griffiths Unannounced Inspection 6th June 2006 10:00 Gloucester Crescent (65) DS0000013528.V298814.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 Gloucester Crescent (65) DS0000013528.V298814.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. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gloucester Crescent (65) Address 65 Gloucester Crescent Laleham Middlesex TW18 1PN 01784 421407 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) Owl Housing Limited Ms Roisin Donnelly Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: Under 65 years, with the exception of one person who may be over 65 years Manager works full time and is supernumerary to care staff at all times That a management structure is in place where a suitably trained and experienced deputy for each home is named for Service Use and staff at all times. That a management structure is in place where a suitably trained and experienced deputy for each home is named for Residents and staff at all times. Management of the homes will be formally reviewed on an annual basis, to ensure management requirements of both services are met by the arrangement. 23rd August 2005 4. Date of last inspection Brief Description of the Service: 65, Gloucester Crescent is a home for 6 residents with a learning disability. The home is situated across the road from another Owl Housing Ltd home and residents from both homes meet up regularly and often share the same staff team including the manager who is registered for both homes. The home offers accommodation for single occupancy with bedrooms on the ground and first floor of the detached property. Car parking is available on the road. Transport is available for residents to go out. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Damian Griffiths was assisted throughout the inspection by the Deputy Manager Mr Sundip Ghedia representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new Inspection record is compiled from details received from a preinspection questionnaire from the home and notifications of significant events known as regulation 37. Comments and complaints received and previous inspection reports are all considered for inclusion prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page this Inspection report. The inspector was with staff and residents at 65 Gloucester Crescent for a period of 6 hrs. This time was spent sampling resident’s care need assessments, care plans, contracts and talking to residents and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, allocation of staff skills, daily rotas and training. The specialist needs of the residents were respected at all times during the inspection. Communication was difficult to establish and maintain with some of the residents therefore the Inspector relied on short conversations and observations of daily activity at the home. Six CSCI surveys for resident’s comments were left at the home to be completed with the help and support of the resident’s key worker. The residents at the home were predominately British and they received care and social support from a mutli–national staff group. The inspector needed to visit the home a second time to sample records that were not available due to the absence of the homes manager. This took place on the 13 of June 2006 and coincided with the inspection of the sister home situated at number 100 Gloucester Crescent. The Fee’s range for the service is between £1,465.00 and £1517.19 per week. This includes Rent, Council Tax, Housing Services and Care and Support. The residents pay for any social activities, hairdressing, magazines, and personal items such as toiletries. The inspector would like to extend thanks to the residents, staff and management at 65 Gloucester Crescent for their assistance and hospitality. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home must show some evidence that the residents received an initial assessment of their needs to ensure that the home is able to meet their needs as stated in the home Statement of Purpose and policies and practices. The home must maintain a record of each resident’s documents to include a written contract from the organising body that arranged the service. This is the second time this requirement has been made. The home must ensure that resident’s needs are met and staff follow risk assessments in place or seek advice and do not expose residents to any unnecessary risks. Special regard must be made to the security of the home at night. An immediate requirement was made to improve the security of the home on the 13 June 2006. The home must ensure the premises are suitable for purpose and that the premises internally and externally are of good construction, safe, well maintained, decorated and all parts of the home are kept clean. and that the following areas are actioned: • • • A good spring clean is organised and employing a permanent cleaner is considered. Carpets are cleaned or replaced. Kitchen chairs to be cleaned/refurbished or replaced. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 7 • • • • • • • • • • • The heating/boiler/hot water must be repaired and always available. An immediate requirement was made to on the 13 June 2006. Electrical fuses/trip system must be safe and securely covered and the cupboard locked. Cracks in the landing and residents doorway must be repaired. The garden and patio area must be made safe and accessible, professional help required and weeds are taken out. Old furniture in the garden must be disposed of correctly at an approved dump. Garden furniture stored correctly and replaced as necessary. Lawns are mowed and brambles and bushes are maintained correctly. Manhole covers are secured. Rubbish is cleared and bins properly used and disinfected. Brick wall next door to neighbouring house is repaired. The laundry area has a soap and hand towel dispenser fitted and the home considers whether it should have these fitted in all bathrooms and toilets instead of towels. The management of the home must ensure that at all times suitably qualified competent and experienced staff are working at the care home in suitable numbers to ensure the health, welfare and safety of residents. The management of the home must ensure that all staff are fit to work at the home and have obtained all staff documents as specified in schedule two of the Care Homes Regulations and ready for inspection as required. The management of the home must promote and make provision in all areas relating to health and safety. It was recommended for the manager to complete level 4 NVQ in Management. 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. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 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 the following standard(s): 1,2 and 3. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Statement of purpose and residents guide was clearly set out for the benefit of the residents and others interested in the home. Initial assessments of care were not evident for the majority of the residents however it was apparent that assessments had been carried out at some time. Contracts were not in evidence due to the continual wait for the amalgamation of the service to be completed. EVIDENCE: The statement of purpose was produced and presented in a pictorial form to assist residents. It contained the philosophy of the home, details of the residents group it is intended to assist and stated, how it will meet the individual and lifstyle needs of the group. Only one assessment was in evidence, however, full care plans were evident for all residents. Each care plan was presented well, clearly typed ,regularly reviewed and contained: risk asessment and actions to safe guard the resident. Staff completed daily record sheets for all. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 10 Residents have been at the home for over five years and had previously been patients of the hospitalised system of care. Mergers taking place between the sponsoring authorities and those responsible for the maintenance of the house have caused delays to the completion of resident’s contracts. There has been one vacancy at the home since the previous inspection however this suits the current resources available . Please see the requirements section of this report. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 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 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. Residents benefited by being actively involved with the creation of their care plans and could make good use of the local community despite complex and challenging behavioural care needs. EVIDENCE: Six care plans were sampled and all included a contents list at the front of each care plan clearly indicating each section of the folder. All sections were recorded pictorially and in a clear typeface ,good format and design and had been reviewed and signed by the manager. Personal care needs/ health care needs, activities, diet, medication, behavioral patterns, risk assessment and sleep patterns. Photo’s were to be found wherever it was needed to assist the resident and were made more relevant by the fact that the residents were usually in the photographs. These pictures were all recent and due to the home owning it’s own digital camera, replaceable and easy to update. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 12 Excellent risk assessments and processes were in evidence and therefore residents choices, could be arranged with and supported by staff confident in the knowledge that if any potential challenging behaviour was presented they were aware of stratagies to manage them. An example of a care plan explained that, in the case of one service user, staff should not insist on a trip out or try to persuade him once he has said ‘no’ to this suggestion and adding that he will inform the staff of where he would like to go. There was evidence of regular residents/ tenants weekly meetings and the minutes included a residents wish to go on holiday however, it was only revealed on the day of the inspection that the resident in question would like to go to Wales. Weekly activities were set out in pictorial fashion and placed on notice boards found in the home. One Service uesr had a calender showing what his choice of activities where every day. It was observed that this formed part of the actions identified in his risk assessment. Staff were able to demonstrate the usefulness of the assessment through their practice when the service user had become upset because he had mistaken the day. A member of staff was able to reassure him and by using the calendar, sensitively showed, where he had gone wrong. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 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 the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to access the local community facilities and were encouraged and supported to maintain links with family and friends. Careful measures were taken to ensure the residents received nutritious food regularly at the home. EVIDENCE: The Residents were actively encouraged and supported to pursue their own likes and hobbies such as reading catalogues. Residents took full advantage of the nearby town centre to visit restaurants and fast food places. Some residents liked playing golf and one loved trains so he was supported to visit a restaurant situated close to Waterloo Station. Residents would actively take responsibility for the weekly shopping and prepared food lists and favourites to buy that day. One resident was able to maintain a part time job recycling paper at a local office. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 14 The local community centre offered a weekly event for all residents and presented them with an opportunity for new and old friendships to develop. Personal development could be seen in the form of certificates of achievement for pottery craft displayed in one resident’s room. Close contact with resident’s neighbours at 100 Gloucester Crescent was maintained and residents from this home were visiting on the day of the inspection. Family and friends were encouraged to visit and BBQ’s had been held at the home. A resident of English/African decent is supported to visit ‘Shepherds Bush Market’ to buy Caribbean food products for preparation at home and to maintain a close and loving relationship with her family with regular visits to her parents home. Meals were of each residents choosing and contained fresh vegetables that would be cooked in a way that would make them presentable to residents to maintain a balanced diet and ensure good nutritional value was maintained. Menus were discussed every week and in time for the weekly shop however to ensure greater understanding of residents choice the home was developing a new pictorial method of menu selection. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 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 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. Residents benefited from staff that were sensitive to their needs and were ensuring that all areas of need were being respected including areas of health care and the administration of prescribed medication. EVIDENCE: Each resident has on their care plan folder the definitive form of address they wish staff to use and whether they preferred a male or female for help with personal care. Clothes preferences were respected. Residents preferred to wear their favourite clothes in designs of their wishes such as tartans, bright colours and a preference for untied shoelaces. An Essential Living Plan ,ELP, had been developed to look at specific services designed for each resident at home. It looks in depth at things that are special to each person, such as stacking bricks of a particular colour or regular trips to the ‘snoozelum’ relaxation room at a nearby day centre. These plans help ensure the emotional wellbeing of each resident is considered. Medication administration records were checked. Residents received regular daily health care checks such as: blood sugar levels and these were discussed at staff handover meetings. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Resident’s views were respected and actioned by staff however staff had not always followed their own risk assessment guidelines to ensure the safeguarding of residents. EVIDENCE: Minutes taken at the tenents meetings were acted upon and residents were observed talking or responding to staff about their wishes and views, sometimes in a challenging manner,however, staff always responded with patience and care. An incident took place on the evening prior to the inspection involving an agency staff member who had not noticed that a resident had left the house. Neighbours found the resident wandering around the neighbourhood and contacted the police who were unable to access the home for some time. The resident did not suffer any injury or harm but this did highlight some inadeqacies in the design of the new front door and bad practice by the ‘waking staff’ member involved who was immediately suspended pending an internal investigation and meetings with the Local Social Care Team. Each resident had pictorial explanation about ‘how to make complaints to CSCI’ and details were available to friends and family. Please see the requirements section of this report. Gloucester Crescent (65) DS0000013528.V298814.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The premises were bordering on being not fit for purpose due to the lack of a clear maintenance agreement between the landlord and service provider. EVIDENCE: Arriving at the front of the premises a disused and broken desk was situated on the grass verge at the front of the house. The front door was not in use and the door bell push was found on the pavement. The double glazed front door and windows were a recent improvement however the front door required further adaptation to ensure secure use and was implicated in a recent incident involving a resident who was able to leave the premises during the night because the door was not secured. Visitors were directed, by a sign in the window, to a side door. A tour of the premises took place and it was quickly observed that the home was in need of a good spring clean. Carpets were stained and chairs around the dining table in the kitchen were worn, stained and in need of a thorough clean. The heating was on despite it being a warm day. The deputy manager explained that this was due to problems with the boiler this also affected the hot water supply. The maintenance people had been informed but this was a persistent problem. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 18 The fuse box containing the electrical safety ‘trip’ system to the house was without a cover in a space that was not secured by a lock or suitable catch. Serious cracks were apparent on a resident’s doorframe wall facing the upper stair landing and were visible on both sides of the wall and required replastering. Carpets to stairs and landing were in need of cleaning and fire extinguisher checks were overdue and the laundry area was without a soap and hand towel dispenser. The communal lounge on the ground floor was a narrow dark room despite leading onto a garden patio area and provided a comfortless and bleak area for its residents. The garden and patio area accessible from the lounge was covered in weeds and posed a trip hazard to the residents if they ventured outside. Old furniture had been discarded and was lodged underneath the hedged borders and in various areas of the garden. The lawns were in need of mowing and the bottom of the garden presented a wilderness of brambles and bushes. A manhole cover situated in front of the side patio area was easily moved due to the failure to provide a raised surround that could be found on the neighbouring cover close to the ramped garden access. The rubbish bins were dirty and rubbish was strewn around this area. The wall next to the house on the left side had been partially demolished and in need of repair. The manager commented on the difficulties of establishing regular, efficient maintainence of the property because of inconsistencies experienced due to the lack of a clear agreement between the landlord and service providers responsibility. Please see requirements section of this report. Gloucester Crescent (65) DS0000013528.V298814.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The skill mix of staff met the needs of the residents however staff shortages required care bank and agency staff to be used frequently thus ensuring inconsistencies in care delivery and a possible breach to residents security. Recruitment procedures had not been fully adhered to and there were some inconsistencies. EVIDENCE: Rotas for the day were compared with a sample of staff on duty to establish whether the skill mix was adequate to meet the needs of the residents and, if necessary, to identify where training was required. The homes 2005 business plan confirmed that there were seven staff vacancies. The home therefore has to depend on the ‘Owl Housing care bank’ and agency staff to ensure that the needs of the residents are met. A sample of Owl housing ‘Care-Bank’, agency and full time ‘Owl housing staff’ was taken. The care bank and agency staff information included: Criminal Record Bureaux status and work visa status as was necessary. Agency staff training included: Initial induction, first aid, health and safety, and food hygiene. Three staff employed by Owl Housing files was inspected and contained training that would meet the needs of the residents. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 20 The training folder was well organised and training was listed by the month; in the month of March training contained: safe moving and handling, safeguarding vulnerable adults,first aid and essential lifestyle planning. Four staff files were sampled to review the quality of staff recruitment and staff procedures. This revealed inconsistencies with three of the four staff files sampled such as in the area of staff references: referees differed from those identified on the original job application form, one reference was not signed and another was missing. Also, files did not have complete employment histories these inconsistencies were reported to the manager for actioning. Staff inconsistency and failure to follow the residents risk assessment may have contributed to a vulnerable adult leaving the home at night, an investigation is pending and the staff member suspended. Staff confirmed that the needs of the residents demanded there full attention and cleaning suffered despite regular input by the residents and staff. The manager confirmed that she would be putting forward proposals to employ regular cleaning staff. Please see the requirements section of this report. Gloucester Crescent (65) DS0000013528.V298814.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 41 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Overall, care and respect for the residents was good but conflicted with the overall poor condition and cleanliness of the home environment. Resident’s views were sought at every opportunity but there had not been a recent quality assurance exercise conducted at the home. Health and Safety at the home was compromised by the poor condition of the premises. EVIDENCE: The deputy manager was extremely helpful and attentive with a good working knowledge of the home, staff and residents. On the second visit to the home the manager was equally helpful and knowledgeable and confirmed that she will be completing her level 4 NVQ City in Guilds in Care in July 2006. The home demonstrated efficient record keeping practice in all areas of service user care. Staff were happy and enthusiastic about their work and, throughout Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 22 the day, residents were observed to be confident and able to express their views and feelings. The home was due to complete a self-assessment of the quality of care and it is expected that this will be completed under the requirements of the ‘IBL’ process. Health and Safety was compromised by the need to rectify the following areas: Gardens; manhole covers, rubbish clearence, repairs to adjacent brick wall, old furniture removal, pathways and patios to be cleared and made safe. Hygiene: The laundry room required a soap and towel dispenser and consideration should be given to extend this to all communal bathroom areas found to contain a communal towel. The premises were dusty and dirty and required a good spring clean. The kitchen chair-seating was dirty and required a radical clean or be refurbished using a more suitable material for cleaning. Electrical: the ‘Fusebox/trip switches need protection and required adequate covering and the cupboard be made lockable. All areas relating to the gas boiler and hot water use required urgent attention and an immediate requirement was made on the second visit due to the lack of action and continued delays. Home safety recently highlighted by a resident being allowed to leave the home at night due to the door being insecure and staff inattention. This situation had not been resolved by the second visit to the home therefore an immediate requirement was made. Fire safety:fire drills, one staff to 5 at night, waking nights, risk assessment in place for the fire drill. Fire checks done weekly. Fire drill was adequate however it was recommended that this be reviewed. All other health and safety procedures were in place. Please see the recommendations and requirements section of this report. Gloucester Crescent (65) DS0000013528.V298814.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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 1 25 3 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 2 X Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14(1)(a)(b)(2)(a)(b) Requirement Timescale for action 06/08/06 2. YA5 17(1)(a) & Sch 3 3. YA23 13(4)(b)(6) The registered person must not offer residents accommodation unless a qualified person has initially assessed the care needs of the each resident to ensure that the home is able to meet their needs as stated in the homes Statement of Purpose and policies and practices. The registered person 06/08/06 must maintain a record of each resident’s documents to include a written contract from the organising body, which arranged the service. This was the second time this requirement has been made The timescale of 11/11/05 was not met therefore a new timescale has been agreed. The registered person 06/08/06 must ensure that resident’s needs are met and staff follow risk Version 5.2 Page 25 Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc 4. YA24 5. YA30 6. YA33 7. YA34 assessments in place or seek advice and do not expose residents to any unnecessary risks with special regard to the security of the home at night. 23(1)(a)(2)(b) The registered person (c)(d)(j)(o)(4)(a)(iv) must ensure the premises are suitable for purpose and that the premises internally and externally are of good construction, safe, well maintained, decorated and all parts of the home are kept clean. Immediate action to secure the new front door and repair or replace the boiler system. 13(3)(4)(a) The registered person must make suitable arrangements to prevent infection and the spread of infection by ensuring a clean environment and providing a soap and paper towel dispenser in the sluicing/laundry area. 18(1)(a)(b)(c) 19(a) The registered person must ensure that at all times suitably qualified competent and experienced staff are working at the care home and in suitable numbers to ensure their health and welfare. 19(1)(a)(4)(a)(b) The registered person must ensure that all staff are fit to work at the home and has obtained in respect of staff documents specified in: Para’ 1 to 9 of Sched’ 2 of The Care Homes DS0000013528.V298814.R01.S.doc 13/06/06 06/08/06 06/08/06 06/08/06 Gloucester Crescent (65) Version 5.2 Page 26 Regulations 2001. 8. YA42 12(1)(a)(b)(3) 13(a)(b)(c)(5) The registered person must promote and make provision for the health and safety of residents. 06/08/06 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. Refer to Standard YA38 YA42 Good Practice Recommendations For the manager to complete level 4 NVQ in Management Fire drill was adequate however it was recommended that this be reviewed. Gloucester Crescent (65) DS0000013528.V298814.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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