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Inspection on 08/03/07 for 65 Gloucester Crescent

Also see our care home review for 65 Gloucester Crescent for more information

This inspection was carried out on 8th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users had received an assessment of care need that had been regularly reviewed and assured that personal care and aspirations were being met. Service users` assessed care needs were well documented and staff helped ensure that each service user had the best opportunity to indicate their preferences and care was taken to ensure that service user choice was respected and safeguarded. The service users enjoyed a varied and full lifestyle supported by the staff, parents, representatives and health care practitioners. The service users received health care treatment in a way that was suitable to meet their needs. The home`s complaints procedures were in place and had been put into operation with care and sensitivity that ensured that service users` rights were respected and the Surrey Safeguarding Vulnerable Adults policy and procedure was in place. The manager had ensured that service users benefited from a range of improvements being implemented and had ensured that their views were reflected in the way the home was being run on a daily basis, and that the health and safety of the service users was protected by measures in place.

What has improved since the last inspection?

Service users` care needs had been regularly assessed, including thorough risk assessments that were in place to help ensure that service users would not be exposed to unnecessary risks, with special regard to the security of the home at night. Service users each had an annual agreement from the home listing a breakdown of their rent and the cost of care. The premises were now fit for purpose following an `Immediate Action` requirement made at the last inspection to ensure that the front door was secure and repairs to the boiler system were completed. The home was clean, reasonably tidy and a programme of refurbishment and decoration was being implemented. Suitable arrangements to prevent the spread of infection by providing a clean environment and providing soap and paper towel dispensers in the sluicing/laundry area had been implemented. The home had begun to recruit permanent staff and to include local workers.

What the care home could do better:

Staff must ensure that the medication policy is followed and ensure that service users` tablets and medication to be returned are correctly recorded and stored at the correct temperature. The registered manager must ensure that at all times competent and experienced full time staff are recruited to working at the care home in suitable numbers to ensure that the health and welfare of service users is maintained. The registered person must promote and make provision for the health and safety of residents. Good practice of the improvements was also recommended such as the home to investigate whether relatives and care practitioners know how to make complaints when next auditing the quality of care, that the home replace a worn kitchen worktop, that the home completes new health and safety at home risk assessments in line with the current refurbishment programme and that the home pays attention to borders and shrubs in the garden areas. .

CARE HOME ADULTS 18-65 Gloucester Crescent (65) 65 Gloucester Crescent Laleham Middlesex TW18 1PN Lead Inspector Damian Griffiths Unannounced Inspection 8th March 2007 10:00 Gloucester Crescent (65) DS0000013528.V332775.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.V332775.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.V332775.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.V332775.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 Service Users 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. 6th June 2006 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. Cost £1,143 based on 2005/6. A full break down of the costs was available from the registered manager. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took seven hours, commencing at 10am and ending at 5pm. The visit was completed by Mr Damian Griffith’s, regulation inspector. The registered manager, Ms Roisin Donnelly, was present for the visit and represented the establishment. The care needs of the service users at the home were complex and demanding and staff were required to be competent communicators and to be able to use a variety of communication methods. The inspector ensured that time was spent sampling residents’ care need assessments, care plans, talking to service users and observing interaction between service users and staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, training and the distribution of staff skills compiled in the daily rota. CSCI surveys were sent to the home for distribution to service users, relatives and health and social care practitioners. Surveys were returned that had been completed by keyworkers on behalf of the service users. No other surveys were received in time to be included in this report. The inspector would like to extend thanks to the residents, their relatives, management and staff at 65 Gloucester Crescent for their time and hospitality. What the service does well: Service users had received an assessment of care need that had been regularly reviewed and assured that personal care and aspirations were being met. Service users’ assessed care needs were well documented and staff helped ensure that each service user had the best opportunity to indicate their preferences and care was taken to ensure that service user choice was respected and safeguarded. The service users enjoyed a varied and full lifestyle supported by the staff, parents, representatives and health care practitioners. The service users received health care treatment in a way that was suitable to meet their needs. The home’s complaints procedures were in place and had been put into operation with care and sensitivity that ensured that service users’ rights were respected and the Surrey Safeguarding Vulnerable Adults policy and procedure was in place. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 6 The manager had ensured that service users benefited from a range of improvements being implemented and had ensured that their views were reflected in the way the home was being run on a daily basis, and that the health and safety of the service users was protected by measures in place. What has improved since the last inspection? What they could do better: Staff must ensure that the medication policy is followed and ensure that service users’ tablets and medication to be returned are correctly recorded and stored at the correct temperature. The registered manager must ensure that at all times competent and experienced full time staff are recruited to working at the care home in suitable numbers to ensure that the health and welfare of service users is maintained. The registered person must promote and make provision for the health and safety of residents. Good practice of the improvements was also recommended such as the home to investigate whether relatives and care practitioners know how to make complaints when next auditing the quality of care, that the home replace a worn kitchen worktop, that the home completes new health and safety at home risk assessments in line with the current refurbishment programme and that the home pays attention to borders and shrubs in the garden areas. . Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Gloucester Crescent (65) DS0000013528.V332775.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.V332775.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had received an assessment of care need that had been regularly reviewed and assured that personal care and the aspirations of service users and their relatives were being met. EVIDENCE: Four service users’ files were sampled and showed evidence of regularly reviewed assessment of care needs. Evidence of a recent review and assessment of care need was in place and showed that additional staff had been made available due to an increase in the service user’s care needs. This was also the case for another service user and showed that a seamless service of care was being provided. Two service users commenting in the CSCI survey agreed that they had been asked if they wanted to move into the home. Gloucester Crescent (65) DS0000013528.V332775.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): Standards 6,7 and 9 were inspected. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The assessed care needs of service users were well documented and staff helped ensure that the service users had the best opportunity to indicate their care delivery preference and that the appropriate risk assessment had been implemented. EVIDENCE: Care plans were very clearly produced and easy to read. Care had been taken to ensure that the care plans contained up-to-date and ‘digitally’ produced pictures of the service users, staff and the activities relevant to each section of the care plan, for instance, in the activity section a service user was photographed buying an ice cream. ‘Essential Living Plans’ also featured recent photos that helped inform staff of the service user’s character and individuality. Service users could also follow the pictorial account, for instance a pair of boots and the way the boots were worn were very important details of one service user’s life and his routine. Individual details such as this were contained in all of the service users’ folders. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 11 The routines of service users was well documented and ensured that staff knew how to help service users to do things at certain times of the day, such as sitting in the kitchen while the evening meal is cooked. One service user communicated her needs and choices through body language and facial expressions - smiling or not smiling - and another service user had details of his sayings listed such as, ‘When I say this I mean this’. Staff guidelines were available for individual services users relating to how they made choices and sometimes put themselves at risk. Details of what staff should do if one of the service users put themselves at risk where well detailed. A clear assessment system and scoring chart was in place for all service users. A staff ‘Handover Checklist’ contained details of emergency contact numbers, front door keys, how to support service users by noting the ‘behavioural guidelines’ listed in their care plan folder. In this way the service users’ needs and aspirations were provided and safeguarded. Gloucester Crescent (65) DS0000013528.V332775.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): Standards 12, 13, 15, 16 & 27 were inspected. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users enjoyed a varied and full lifestyle supported by the staff, parents, representatives and health care practitioners. Service users were able to visit and use the local facilities and were supported to accept responsibilities that had been risk assessed. The service users’ daily menu was monitored by staff and health practitioners to ensure that they received the correct nutrition. EVIDENCE: Service users had a diverse and interesting selection of activities that staff helped to maintain. One service user mentioned in the last inspection report was still able to hold down a part-time job and loved train rides to Waterloo. Pottery was enjoyed, and one of the service users who considered himself ‘retired’ liked to potter around the home and keep the staff in line. Other service users were assisted to visit the local cinema. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 13 Service users assisted with the daily home shop, visiting local providers. Visits to the garden centre, restaurants and use of the local bank were encouraged and supported by the staff. Family contacts and friendships were supported and maintained. A caring relationship between service users was respected and service users were able to develop this as they wished. Photographs of family gatherings and birthday celebrations were in evidence. Excellent weekly timetables were produced in a pictorial fashion that showed the service users actually doing the things they were scheduled to do, such as visiting the shops. Staff were made aware of special diets required for service users with diabetic and other health related conditions. A dietician had been working closely with the home to ensure that diets were monitored closely. Gloucester Crescent (65) DS0000013528.V332775.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): Standards 18,19 and 20 were inspected. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The service users received health care treatment in a way that was suitable to meet their needs. The daily medication administration records were in order and policies were in place that safeguarded the service users. However, some improvements were needed. EVIDENCE: Service users’ care plans contained evidence of staff commitment to support and protect their healthcare needs. Recognition of service users’ difficulties in maintaining a healthy diet was dealt with sensitively and there was evidence of strategies being discussed. Full healthcare details such as diabetes care, epilepsy, hay fever and mobility were available in the service users’ care plan folders and clearly described what actions needed to be taken in the event of an attack and listed the appropriate risk assessment and response for service users and staff. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 15 A clear list of service users’ medication was available in every care plan. Prescribed medication was provided daily by two staff members who had received the appropriate training, one staff member to administer and one to witness the administration and the signing of the ‘medical administration record’. The home’s medication practice was in need of improvement in order to meet the changes introduced by the pharmacy services, due to some medication no longer being made available in ‘blister packs’. The prescribed medication had been distributed to the home in packets and the tablets prescribed needed to be counted and recorded in the medication administration record. There was also no record of medication to be returned to the pharmacy and there was no ‘returns book’ available for inspection’. The home needed to confirm that the service users’ medication was being stored at the correct temperature. The manager agreed to consult the pharmacy to conduct an audit of the home’s practice and ensure that staff were enrolled on a new training course that was currently available from the pharmacy. Comments from the five service user CSCI surveys received stated that service users at the home during the weekend and not visiting relatives enjoyed going out for a drive and relaxing. Gloucester Crescent (65) DS0000013528.V332775.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): Standards 22 and 23 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedures were in place and had been put into operation with care and sensitivity that ensured that the service users’ rights were respected and the Surrey Safeguarding Vulnerable Adults policy and procedure was in place. EVIDENCE: There were three complaints listed in the complaints book. They included two from neighbours concerning noise and service users being observed unescorted outside of the home and one complaint received from the local cinema. Care had been taken to reply to all parties involved. Actions had been taken including neighbours being invited to meet service users and prompt replies by letter. Evidence of the complaint from cinema staff had not been upheld. The account given showed that staff (agency) had needed to reassess the risks involved very quickly and had managed the situation very well. New guidelines in place showed that a ‘one-to-one’ staff and service user ratio would be used. Two CSCI surveys completed by relatives showed that they had never needed to complain. However, they were not aware of the complaints procedure. It is recommended that the home considers this in their next quality care audit. Four out of five service users assisted in completing the CSCI survey had commented about how they would be able to make their complaints known to staff, ranging from talking to staff to making facial expressions. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 17 Staff had received training and action taken recently had showed evidence that the home responded properly and activated the Surrey multi-agency procedures to safeguard vulnerable adults. There were currently no investigations in progress. Please refer to the recommendation section of this report. Gloucester Crescent (65) DS0000013528.V332775.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): Standards 24, 25, 26, 27, 28 and 30 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was in the process of a much needed refurbishment programme. Service users were able to benefit from individualised bedrooms and a relatively clean and comfortable environment that was set to improve. EVIDENCE: Garden rubbish and old chairs had not been removed since the last inspection. However, a skip had been ordered for the following day and would enable a thorough clear out of house and garden rubbish. All the lawns had been mown, but attention to borders and shrubs is recommended. The home was in the process of being refurbished. Interior decoration was being completed in one of the two living rooms. Carpets throughout the house were torn and badly stained and the problem had been exacerbated due to an outbreak of sickness and diarrhoea. The manager had taken appropriate infection control measures and informed the inspector that all the carpets and flooring throughout the home were being replaced at the end of the month. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 19 The central heating system was in good order and maintenance work had been completed to the front door so that it could be left on the latch and not lock out the service users. The side door had been fitted with brass bolts and one of the service users, mentioned in the ‘Complaints’ section of this report, had begun to take care to lock the door using the bolts provided, rather than wondering off. Service users’ bedrooms were clean and tidy. Some had recently been decorated. All the rooms showed the style and individually of each of the service users. Bathrooms were clean and were also waiting to be repainted. New furniture, seating, fixtures and fittings were going to be provided. The laundry room in use clean and tidy with hand washing facilities in place. The home has addressed the problem of home hygiene, mentioned in the last report, by ensuring that cleaning staff were employed. The cleaning was, however, being hampered by the poor condition of the carpets throughout the home. Plans to refurbish the kitchen were in place and the manager informed the inspector that new flooring was to be fitted. It was recommended that the home replace the worn kitchen worktop. Please see the recommendations section of this report. Gloucester Crescent (65) DS0000013528.V332775.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): Standard 32, 33, 34 and 35 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home staffing levels were in need of permanent staff members, but the staff provided from Owl Housing’s own care bank and the staff from the care agency were competent and able to help and support service users. EVIDENCE: Staff and service user interaction observed on the day of the inspection showed that the staff provided adequate care to ensure that basic personal care needs were being met and that service users were safe and comfortable. Owl Housing Association’s own care bank staff supplement staff whenever permanent staff are not available or if additional care needs arise. Good practice was evidenced at the home due to two separate instances where additional staff were being funded to cover service users’ assessed needs. The management stated that staff vacancies in the home meant that cover was required from care bank and care agency staff on each daytime shift to ensure that sufficient numbers of staff were available. This was also evidenced through the sampling of staff rosters. However, the home sought to ensure continuity of care by employing the same staff from the care agency. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 21 A good range of training was in evidence of the staff listed on the staff rota for the day including protection of vulnerable adults, health and safety, fire, medication, induction and National Vocational Qualification Levels 2,3 and 4. The manager is committed to training her staff and ensures that staff are knowledgeable regarding the complex needs of the service users. One new staff member had been recruited. However, the assistant director post had become vacant and the new deputy was acting up. Support was being received from the area manager. The home was managing this situation well. However, the home must have a complete staff team to guarantee continuity of care. The care agency used had provided a letter of confirmation that all staff had received a criminal record check and staff also carried an identity card listing core training required. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38 and 42 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager had ensured that service users benefited from a range of improvements being implemented and had ensured that their views were reflected in the way the home was being run on a daily basis. The implementation of health and safety measures in place at the home protected service users. EVIDENCE: The registered manager had completed her National Vocational Qualification Level 4 in Home Management. A home improvement action plan was in place listing named staff responsible to meet the timescales of the improvements to the home and the range of home improvements. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 23 Arrangements to improve the maintainence management of the home was beginning to emerge in the form of a statement from Property Services containing a list of responsibilities and listing improvements to the service. The home’s budget was in place and only slightly overspent on energy costs, but lots of investment on the structure of the home. A recruitment drive was in place and moves to advertise locally were being planned. The balance to protect service users and maintain harmony within the immediate community were evident due to a series of incidents involving service users leaving the home unescorted, causing concern to neighbours. The home had improved its security measures, acknowledged its shortcomings and handled service users’ human rights and neighbours’ concerns with sensitivity. Service users choices, influence and rights were reflected in the way the home managed service users’ meetings, and care plans that specifically stated their likes and dislikes. The home provided evidence that it was preparing ‘quality assurance questionnaires’ for service users and their representatives. The manager had sought advice in the management of an outbreak of sickness and diarrhoea from the environmental health department and service users were observed being well cared for on the day of the inspection. Fire drills were completed regularly, with another due, and fire equipment was checked. It was recommended that the home replace the worn kitchen worktop and that the home complete new health and safety at home risk assessments in line with the current refurbishment programme. Five service users had been assisted to complete the CSCI surveys sent to the home. All agreed that they could make decisions about what to do each day. All had agreed that they could do what they wanted during the day and the evening. All agreed that they could do what they liked at the weekend. Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 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 2 25 3 26 3 27 3 28 3 29 X 30 3 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 4 4 X 4 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 2 X 3 X 3 X X 3 X Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 25 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. Standard Regulation 13(2) Schedule3 (3)(i) Requirement Staff must ensure that their medication policy is followed and ensure that service users’ tablets and medication to be returned are correctly recorded and stored at the correct temperature. The registered manager must ensure that at all times competent and experienced full-time staff are recruited to working at the care home in suitable numbers to ensure that the health and welfare of service users is maintained. Timescale for action 08/04/07 1. YA20 2. YA33 18(1)(a)(b)(c) 19(a) 08/04/07 3. YA42 12(1)(a)(b)(3)1 The registered person must 3(a)(b)(c)(5) promote and make provision for the health and safety of residents. 08/04/07 Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 26 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. 3 3. Refer to Standard YA24 YA38 YA39 Good Practice Recommendations All the lawns had been mown but attention to borders and shrubs was recommended. It was recommended that the home replace the worn kitchen worktop. It was recommended that the home investigate whether relatives and care practitioners know how to make complaints by including this in their next quality care audit. It is recommended that the home replace the worn kitchen worktop and that the home completes new health and safety at home risk assessments in line with the current refurbishment programme 4. YA42 Gloucester Crescent (65) DS0000013528.V332775.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection OxfordArea Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Gloucester Crescent (65) DS0000013528.V332775.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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