CARE HOME ADULTS 18-65
Arbours Crisis Centre Arbours Crisis Centre 41a Weston Park Hornsey London N8 9SY Lead Inspector
Jackie Izzard Key Unannounced Inspection 18th January 2007 10:45 Arbours Crisis Centre DS0000027800.V322934.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 Arbours Crisis Centre DS0000027800.V322934.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. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Arbours Crisis Centre Address Arbours Crisis Centre 41a Weston Park Hornsey London N8 9SY 020 8340 8125 020 8342 8849 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) Arbours Housing Association Ltd No registered manager Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: The Arbours Crisis Centre is registered as a care home for people with mental health problems. The centre is registered to accommodate six adults. The Crisis Centre is part of a range of services offered by the Arbours Association, a registered charity that describes in its core mission statement that it offers personal, psychotherapeutic support and places to live, outside of mental hospital, for people in emotional distress. The centre is a large house on four floors with the six single bedrooms for the guests on the first, second and third floors. The fourth floor is used by resident therapists, who live at the centre. There are three lounges and a kitchen diner on the ground floor. The house has a large well maintained garden with a studio which is used for a range of activities, such as art therapy. The house is situated in the heart of Crouch End, North London. There is easy access to all local amenities. The stated aim of the centre is that it provides intensive personal, psychotherapeutic intervention and support within the context of a noninstitutional therapeutic community environment. The fee for living at the Crisis Centre is from £1960.00 per week. Following “Inspecting for Better Lives”, the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on 18 January 2007 at 10.45am and lasted six hours. The inspection was unannounced, so nobody at Arbours knew the inspector was coming. The inspector met two of the three resident therapists, the manager of the centre, a team leader and the three people currently staying at the centre. People staying at the Crisis Centre are referred to as guests, so this is the term used in this report. The inspector looked at records kept in the centre and followed up the requirements made at the previous inspection in October 2005 to see if Arbours had carried out the things they were asked to do at that inspection. A tour of the premises was also carried out along with discussion with the manager, team leader and two of the three guests. The inspector also had lunch with the guests and resident therapists. What the service does well: The Crisis Centre offers a unique service for people who are experiencing mental health problems/emotional distress. The centre uses the model of a therapeutic community. There are three community meetings each week and each guest has three sessions of psychotherapy each week with a team leader and a resident therapist. In addition, Art therapy is offered on a weekly basis along with movement therapy and yoga. The centre provides continuity of care, in that there are three resident therapists who live in and a small team of therapists who stay at the centre at weekends when the residents therapists have weekends off. Individual psychotherapy is with the same therapists throughout the guest’s stay and can be continued after they leave if this is appropriate for them. The house is attractive with good-quality furniture, and guests choose how they decorate their own rooms and also choose the decor for communal areas. The house is homely and welcoming. An attractive and well maintained garden is provided, complete with pond and a wooden studio building which can be used for individual and group activities. Guests are encouraged to be as independent as possible and to take responsibility for themselves. At the same time, a high level of emotional
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 6 support, intensive psychotherapy, good food and a comfortable homely environment in a quiet residential area is provided. What has improved since the last inspection? What they could do better:
Two requirements made at the last inspection of the home have not yet been met, and have been restated in this report with a new timescale for compliance. In the timescale for action column, the date in ordinary type relates to the timescale given at the last inspection, the date in bold type relates to the new timescale. Further information regarding unmet requirements can be found in the relevant standard. Unmet requirements can impact upon the health and safety of service users. Failure to comply with the timescales will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. The Arbours Association need to ensure they have taken out proper checks on any new therapists before they start to work at the Crisis Centre. A requirement was made at inspections in May and October 2005 to ensure they obtain a satisfactory CRB (Criminal Records Bureau) check before allowing someone to begin work at the Centre. Although they agreed to this, another resident therapist has been employed since that inspection before Arbours had taken out a new CRB check on that person. A CRB undertaken by another employer was accepted by Arbours. An immediate requirement on this issue was made for the second time. A requirement to ensure an application is made to the Commission for Social Care Inspection to register a manager for the Crisis Centre is restated for the second time. However, the new manager told the inspector she is about to apply for registration, which is positive. Six new requirements were made at this inspection. A requirement is made to ensure fire safety tests are carried out and recorded properly as the test of the fire alarm were seen to be recorded two weeks in
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 7 advance. A requirement is also made to keep lobby doors free from obstruction as these are fire doors and to repair or replace a fire door which has a gap underneath. A requirement is also made to have an emergency fire plan in place which all staff and guests are aware of. Staff must attend basic training in giving medication and this training must be accredited. Records of guests’ health appointments and the outcome of these appointments must be made for any guest who is not independent in this area, as evidence that they are being supported with their health needs. 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. Arbours Crisis Centre DS0000027800.V322934.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 Arbours Crisis Centre DS0000027800.V322934.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): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective guests are fully informed about the services offered at the Crisis Centre and what will be expected of them, before they move into the centre. Admissions to the centre are carefully planned in order to meet the guests needs. People are fully aware that they will be expected to engage in the therapeutic programme and have a clear contract of the terms and conditions of their stay. The quality of written assessments varies and greater consistency would help guests to know that their individual needs and aspirations have been assessed. EVIDENCE: Admissions to the Crisis Centre are well planned. The admissions procedure is detailed and clear. Before moving into the centre, the guests will visit the centre. Prospective guests have the opportunity to visit the centre on a number of occasions before making their decision to move in. Guests are given a contract with the terms and conditions of their stay which they are Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 10 required to sign. The inspector saw a copy of such a contract in two guests’ files. The quality of the assessment recorded in guests’ files varied. One was good and one was very basic. This is an improvement on previous assessment records seen and is an indication that Arbours are trying to produce more consistent records. Arbours Crisis Centre DS0000027800.V322934.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guests’ care plans vary in content but the quality of care plans is improving which should benefit guests. Guests are encouraged to make their own decisions with support as needed. EVIDENCE: Of the three guests’ files seen, all three had a care plan and some kind of risk assessment. One had a basic plan, which did not meet National Minimum Standards and did not address the person’s global needs. The other two care plans were of a better standard, showed evidence of assessment of the guest’s needs and the plan had been reviewed regularly. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 12 One risk assessment was very basic but the other two were of a satisfactory standard and showed evidence of discussion of the risks to that guest’s safety and wellbeing. The inspector met all three of the current guests and met with two of them individually to discuss their views and experiences of living at the Crisis Centre. From these discussion, it was clear that guests are encouraged to be independent and be responsible for themselves with a level of support which varied depending on their needs. Arbours Crisis Centre DS0000027800.V322934.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying at the Crisis Centre are offered a unique opportunity for intensive personal development. They are encouraged to live a good quality lifestyle with good food, and support to follow their personal interests and to maintain and develop their relationships. People are treated with respect and encouraged to take responsibility for themselves. . EVIDENCE: At the time of the inspection, none of the guests were in employment or adult education. One guest said she was considering employment. Within the Crisis Centre, guests attend three therapy meetings each week and four group meetings along with art therapy, movement therapy and yoga. One of the group meetings is a creative activity where guests choose to either go out for a walk, play games , do some artwork, etc.
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 14 Guests would like more structure; ie more organised activities but time to think and spend unstructured time in the house is seen as part of the therapeutic programme. At Christmas time, more activies were organised and guests went ice-skating, to a pantomime and other trips out together. People make their own choices about how and when they have contact with family and friends and can retain an independent social life outside the centre as long as this does not conflict with the therapy sessions they are expected to attend. Locks on bedroom doors mean that guests have sufficient privacy. Smoking is allowed only in the conservatory so that it does not impinge on the rights of guests to live in a smoke free envirmenment. Some guests who stay at the Crisis Centre have difficulties with eating/eating disorders. Risk factors regarding eating difficulties is addressed in the healthcare section of this report. Guest are fully involved in decisions regarding running the centre and have a housekeeping meeting weekly. Cooking is shared and support to cook for the group is available from the Resident Therapists. The inspector was invited to eat lunch with guests and resident therapists and was able to confirm that a high quality of food continues to be served. Guests eat as a group. Arbours Crisis Centre DS0000027800.V322934.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guests are able to control their own medication if they wish to but would be better protected by the centre’s practices in medication administration if staff attended basic training in this area. Guests receive good personal support but improved records are needed to assure them that their health needs are known and are fully addressed. EVIDENCE: At the time of this inspection, one guest was receiving support with personal care and two were independent in this area. Consistency is provided by a team of three resident therapists and others cover when these therapists are our of the centre at meetings or days off. Three guests’ files were examined for evidence of their health needs being assessed and met. One showed evidence that the guest’s health needs were known to staff and that she had been given the appropriate support to attend appointments. Health was not addressed in one guest’s care plan.
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 16 The other had no record of health appointments despite being dependent on staff to attend health appointments and there being current concerns about her health. A requirement is made to ensure that health needs are recorded and met and records kept of health appointments and their outcome. One guest sees a psychiatrist regularly and others when needed. The manager was able to explain the centre’s procedures regarding medication and the inspector looked at the medication cabinet and records. A staff member dispenses medication into dosette boxes on a weekly basis which is no longer seen as good practice. At the time of the inspection, two guests were taking prescribed mediation. There were some gaps in a guest’s medication records where no explanation had been recorded as to why the guest did not receive her medication as prescribed. Medication was stored securely and safely. Guests have suitable lockable storage space if they were to keep their own medicines. Since the last inspection of the Crisis centre, the registration category has changed, at Arbours’ request, from a nursing home to care home. Now that there is no longer a nurse on duty at all times, none of the staff have been provided with training on giving medication and a requirement is made that this accredited training be arranged and that a key is recorded on the administration sheet to explain why a medicine was not taken. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests’ views are listened to and there is clear written guidance on how they can make a complaint. They benefit from a team of staff who are experienced in working with people who self harm. EVIDENCE: There is a clear complaints procedure if a guest wishes to make a formal complaint. There is opportunity to air their views and grievances at the house meetings three times a week. The complaints procedure was inspected in May 2005 and found to meet the required standard. The manager confirmed that the procedure remains the same as at that time. There have been no formal complaints in the last year. There have been no adult protection investigations regarding anyone staying at the centre. The manager and team leader said they were aware of the procedures to follow in the event of an allegation being made of abuse. The inspector discussed self harm with the manager and team leader. There are no current concerns about self harming. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Crisis Centre is clean and hygienic and the guests benefit from staying in a homely, comfortable and attractive environment with a choice of spaces to spend private time in or be in the company of others. EVIDENCE: The house is well situated, in a quiet residential street where it blends in with domestic houses, but also a short walk to the centre of Crouch End and all its amenities. There is easy access to buses. The house comprises; a kitchen where meals are eaten, conservatory, large lounge for communal use, large lounge for therapy sessions and meetings, small lounge, bathrooms, toilets and bedrooms. There are six guests’ bedrooms and three for resident therapists, who live in. There is also an office. There is a well maintained garden with pond and outside studio, which is used for art therapy and other small group or individual meetings/activities.
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 19 There is therefore a range of spaces where guests can be part of the group or spend time alone. Since the last inspection, there has been some redecoration, a new stair carpet, laminated flooring and a new rug in the lounge as well as electrical rewiring and a new fire alarm system installed. Guests have been given locks on their bedroom doors to give them more privacy. One guest told the inspector s/he was pleased to have a lock on his/her bedroom door. Rooms vary in size and shape so guests can choose a room that suits their own personal tastes. Communal rooms were seen and the standard of cleanliness was observed to be very good. The conservatory is the designated smoking area so the rest of the house is smoke-free for guests. Laundry facilities were not inspected on this occasion. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guests benefit from staff who receive training relevant to the work they are doing but guests are not always protected by the centre’s recruitment practice in that staff have been allowed to start work at the centre before a Criminal Records Bureau check had been taken out by Arbours. EVIDENCE: Staff employed to work with guests include the manager of the Crisis Centre, resident therapists and team leaders. The team leaders are responsible for the care plan, assessments and therapy programme of guests and the resident therapists are responsible for day to day support and care, as well as being part of the therapy team. Each team consists of the team leader, a qualified psychotherapist, a resident therapist who is training with Arbours and the guest. The manager is also a psychotherapist. Staff are therefore well equipped to carry out the aims of the Centre and offers intensive psychotherapeutic work with the guests. Although the majority of staff records inspected showed evidence of a thorough recruitment process, one staff had been appointed with a Criminal Records Bureau check carried out by a previous employer. The issue of having
Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 21 up to date CRB checks carried out by Arbours’ own umbrella body, before a person starts wok with guests has been the subject of previous requirements in inspection reports. A requirement to ensure that all staff/volunteers are properly vetted is therefore restated and an immediate requirement was issued to this effect. This staff member also had only one reference on file instead of the required two. The manager said that first aid training is booked for the resident therapists. Arbours Crisis Centre DS0000027800.V322934.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): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Guests benefit from a well run centre where their views are considered and where self monitoring takes place. Their health and safety will be better protected as the centre continues to improve on fire precautions. EVIDENCE: There have been two changes of manager since the cast inspection of the crisis Centre. However, the new manager has a psychotherapy qualification and is discussing the requirement for management training which shows a commitment to the role. The new manager told the inspector she is about to apply for registration, which is very positive. There have been improvements in the management of the centre with regard to record keeping. Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 23 One of the team leaders has played an important part in helping the centre comply with the National Minimum Standards of care Homes and sets a good example in developing care plans. The inspector discussed quality assurance with a team leader and the manager. Ex guests of the centre are given questionnaires to complete t help with the consistent monitoring of the quality of service provided. Arbours are planning to use a recognised evaluation tool and to conduct annual interviews with guests by an independent visitor. This is positive. The centre has a strategic development plan which the inspector had the opportunity to read. This showed evidence of forward planning and had targets for the next few years, showing a clear sense of direction. Fire safety was looked at in some detail on this inspection, including examination of the centre’s fire risk assessment, fire alarm and equipment test records, a sample of the monthly fire safety inspections carried out by the Arbours’ fire safety officer and a tour of the building looking at fire safety issues. Improvements made since the last inspection are; developing a fire risk assessment, repairing faulty emergency lighting and installing a new fire alarm and detectors system. The last recorded fire drill was in November 2006 and these have been taking place on a regular basis. One fire door was found to have a gap underneath and a requirement is made to repair or replace this door. Advice was also given to check that all fire doors fit the doorways properly to form a seal against the spread of fire. There were some ironing boards and a hoover near to fire lobby doors outside bedrooms and a requirement is made to move these items so that they do not obstruct people if they need to get out quickly in the event of a fire. The centre has a contract with a new company to inspect and service the fire alarm system and equipment which is positive. It is the responsibility of staff at the centre to test the fire alarm each week. Records showed this had been recorded for 22 and 29 January 2007 in advance so a requirement is made to ensure this is only recorded when actually carried out each week. There were two different fire evacuation procedures on walls around the centre. The inspector advised that a fire emergency plan be devised as a matter of urgency and a requirement is made to do this. Guests can then be given a copy to ensure they are aware of the procedure to follow. Arbours Crisis Centre DS0000027800.V322934.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 3 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 3 25 4 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 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 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 X 3 X X 2 X Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 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 YA34 Regulation 19(1)(b)(i) Requirement The registered person must ensure that Arbours obtain a new CRB enhanced disclosure for any person who works at the centre on a paid or voluntary basis before that person starts work. This requirement is restated. Previous timescale of 24/05/05 and 27/10/05 not met. This is an immediate requirement. The registered person must ensure that an application is made to the CSCI to register a manager for the Crisis Centre. This requirement is restated. Previous timescale of 30/8/05 and 30/03/06 not met. Timescale for action 19/01/07 2. YA37 8, 9 30/03/07 3. YA20 13(2) The registered person must also inform the CSCI when a manager leaves the crisis centre. The registered person must 30/03/07 ensure all staff who give out medication have attended training, which must be
DS0000027800.V322934.R01.S.doc Version 5.2 Page 26 Arbours Crisis Centre accredited. 4. YA20 13(2) The registered person must ensure that medication records are accurately kept with reasons why a medicine was not taken recorded on the chart. 23(4)(c)(iii) The registered person must ensure the centre has an emergency fire plan which all staff and guests have been informed of. 23(4)(c)(i) The registered person must repair or replace any fire door which is not effective. 30/01/07 5. YA42 18/02/07 6. YA42 18/02/07 7. 8. YA42 YA19 23(4)(c)(v) 12(1)(a), 13(1)(b) The registered person must also ensure that all staff and guests do not obstruct fire doors or fire exits at any time with items of furniture or equipment. The registered person must 18/02/07 ensure fire alarm test records are accurate at al times. The registered person must 18/02/07 ensure guests’ health care appointments and the outcome are recorded as evidence that their health needs are being met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Arbours Crisis Centre DS0000027800.V322934.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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
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