Inspection on 03/01/06 for Blake Court

This inspection was carried out on 3rd January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blake Court 27/08/09

Blake Court 05/09/08

Blake Court 06/09/06

Blake Court 22/09/05

Blake Court 07/02/05

Blake Court 03/12/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

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

CARE HOME ADULTS 18-65 Blake Court Flat 5 5a Barrow Road Waddon Croydon Surrey CR0 4EZ Lead Inspector Lee Willis Unannounced Inspection 10:25 3 January 2006 rd Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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 Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Blake Court Address 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) Flat 5 5a Barrow Road Waddon Croydon Surrey CR0 4EZ 020 8688 2682 020 8688 2682 SCOPE Mrs Carol Jones Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users aged over 65 to be accommodated. 22nd September 2005 Date of last inspection Brief Description of the Service: Blake Court is owned by Croydon Churchs Housing Association, but managed and staffed by the registered charity - Scope. The scheme is registered with the Commission for Social Care and Inspection to provide accommodation and personal support for up to six younger adults with Cerebral Palsy and a broad range of associated physical disabilities. Carol Jones remains the schemes registered manager where she has been in operational day-to-day control for the past two and a half years. Situated on the ground floor of a residential apartment block these five purpose built flats are all self-contained and have there own front doors, open plan lounge and kitchen areas, separate bedrooms, and en-suite toilet and bathing facilities. All the flats are wheelchair accessible and have been provided with suitable environmental adaptations and disability equipment to meet the individually assessed needs of the occupants. There is also a separate staff office, sleep-in room, and kitchen and toilet/shower facilities also located within the block, which is separate from the occupants living quarters. Located in the heart of Waddon, a residential suburb to the South of Croydon, the scheme is well placed for accessing a wide variety of local shops, cafes and pubs. The flats are also located quite near a number of main line bus routes and Waddon train station is within a quarter of a mile radius of the scheme with excellent connections to central Croydon, London and the surrounding areas. The central objective of the scheme remains to support the occupants to maximise their independence and to take as much control as practicable over their own lives. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 10.25 on the morning of Tuesday 3rd January 2006. It took four and three quarter hours to complete. Since the schemes last inspection the Commission has not received any comment cards in respect of this service. The majority of this inspection was spent talking to the registered manager of the scheme, four of the occupants who were all at home at the time of this unannounced inspection, and a couple of members of staff who were on duty at the time. The rest of this inspection was spent examining the schemes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months, although an allegation of abuse has been received by the Commission during this time, which is currently being investigated by Scope in accordance with vulnerable adult protection protocols. What the service does well: The vast majority of the occupants met during the course of this inspection expressed satisfaction with the overall standard of care they received at Blake Court. Most said they liked living there. It was evident from the care practise of staff and comments made by most of the occupants met that the scheme continue to achieve its primary aim of ensuring the occupants freedom of choice and independence is maximised. For example, it was positively noted that one occupant who had expressed an interest in possibly transferring to another Scope home in the area where there was more communal space, was not only being listened too, but actively encouraged to participate in the decision making process. It was also positively noted that care plans continue to be reviewed at regular intervals and up dated accordingly to reflect individual’s occupants changing needs. Finally, records showed the schemes current staff team had changed very little in the past twelve months, ensuring the service users receive continuity of care from a relatively small group of experienced support workers who are familiar with their unique needs, wishes and preferences. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The schemes admissions procedures are sufficiently robust to ensure staff can plan for and meet prospective new occupants assessed needs. EVIDENCE: As the scheme remains fully occupied the manager has not received any new referrals in the past twelve months, although discussions are currently on going about the possibility of one occupant transferring to another Scope home in the area. It was evident from the comments made by the aforementioned occupant that their wishes and feelings about any potential move are being actively sought and taken into account. The manager and one other member of staff spoken with at length both confirmed that the scheme was finding it increasingly difficult to continue meeting the emotional changing needs of this particular occupant. The same member of staff went onto to say that the increased demands being placed on the staff team was beginning to have an ‘adverse’ affect on the schemes ability to continue meeting the daily health and welfare needs of the other occupants who currently reside at Blake Court. The manager is confident that a final decision regarding the possible move will be taken by the end of January 2006. The manager has agreed to keep the Commission up dated and said the individual concerned would be involved at every stage of the decision making process. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 9 The registered manager demonstrated a good understanding of Scopes admissions procedures and the criteria to be used when considering any new referral. The manager said all the occupants would be consulted before any prospective new occupant was offered a place at Blake Court and the individuals compatibility with the others already residing their always taken into account. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Care plans continue to accurately reflect occupants assessed and changing needs and are sufficiently detailed to enable staff to plan for and meet their unique needs, personal goals and wishes. Staff actively encourage and support the occupants to take ‘responsible’ risks whenever practicable, although there was a lack of recorded evidence to show that all potential risks to occupants and staff had been thoroughly assessed. It is essential that agreed risk management strategies are included in care plans to enable staff to minimise the likelihood of these identified risks occurring and to help them deal consistently with them when they do. EVIDENCE: Having inspected three care plans at random it was positively noted that not only had all three been reviewed at least once in the past six months, in accordance with National Minimum Standards, two of them had actually been reviewed more frequently to accurately reflect their needs, which had significantly altered in the past few months. These reviews had involved the occupants, their families and significant others, including both social and healthcare professionals (e.g. Care managers, occupational therapists, the Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 11 schemes manager…ect). As mentioned in the previous section these reviews are an integral part of the process of ensuring the service providers can continue effectively planning for and meeting the occupants changing needs and wishes. It was evident from comments made by several of the occupants spoken with at length that staff continue to actively encourage them to take ‘responsible’ risks as part of a structured programme to maximise the occupants independent living skills. One occupant said they liked to do their own washing up and help staff prepare meals. As previously mentioned, a couple of occupants needs have significantly altered in recent months, and despite assurances from the manager that staff have been fully briefed about how to deal with behaviours that may challenge the service, as well as falls, no record of the management strategies agreed to minimise risk were available on request. Risk assessments detailing all the action to be taken by staff to deal with the aforementioned occurrences, including all the possible causes, must be included in each occupants individual care plan. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 & 17 Social, leisure and employment opportunities for occupants to engage in both inside their flats and in the wider community are well managed, age appropriate, and provide the occupants with daily variety and stimulation. Meals are nutritionally well balanced and provide daily variation and interest for the people living at Blake Court. EVIDENCE: All the occupants asked about what opportunities they had to engage in social and leisure activities said that in the main staff always helped them to find out about and pursue their own interests and hobbies. For example, one occupant has recently been for a interview for a post as a volunteer at a local hospital and another who has decided they no longer want to attend a local day centre is being encouraged to look into the possibility of enrolling on a cooking class. Over the Christmas period the manager said one occupant went away with family and the rest chose to spend Christmas Day in their own flats with staff and fellow occupants. All the occupants asked about the schemes Christmas party said it had been a great success. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 13 All four occupants met said they had all received a lot of visitors over the Christmas period, who they entertained in the privacy of their flats. It was positively noted that the schemes rules on smoking had finally been formalised, which the occupants and staff had helped draft. Occupants can choose to smoke in their flats and staff may only smoke outside, in a designated smoking area. During a tour of the scheme it was noted that one occupant had been supported by a member of staff to make what appeared to be an extremely nutritious and well presented vegetable and potato casserole, which the occupant confirmed was as delicious as it looked. It was also positively noted that a new agency member of staff was seen appropriately assisting one occupant to eat their lunch. There approach was very relaxed and unhurried, and they also sat in full view of the occupant ensuring they had good eye contact with them. The occupant’s husband said his wife loved Marmite and cheese sandwiches for lunch, but he was not keen and would be choosing something else for his lunch. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Suitable arrangements are in place to ensure the occupants assessed, as well as changing physical and emotional health care needs, continue to be identified, planned for, and met. EVIDENCE: The schemes incident book revealed that there had been no unplanned admissions to hospital since September’05. The one occupant who was out at the time of this inspection was attending an outpatient’s appointment with a member of staff. As previously mentioned, a couple of the occupants needs have significantly altered in recent months and as a result staff have had to deal with a increased number of falls involving the same occupant. One member of staff spoken with was concerned about the moving and handling implications of these changes. This matter was discussed with the manager who was able to confirm that an appointment for an Occupational Therapist to reassess this particular occupants needs was set to take place on Thursday 5th January’06. The manager said she will forward a copy of the subsequent assessment to the Commission and will consider any environmental adaptations and moving equipment recommended by the OT in their report. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 15 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 & 23 On the whole the schemes arrangements for dealing with complaints are sufficiently robust to enable the occupants to feel confident that any concerns and/or complaints they have will be listened to and acted upon, although records of these complaints must be kept in greater detail to enable anyone authorised to inspect these documents to determine whether or not appropriate action was taken to resolve them. The schemes arrangements for dealing with suspected or alleged incidents of abuse are sufficiently robust to ensure the occupants are protected, so far as reasonable practicable, from avoidable harm and/or abuse. EVIDENCE: The schemes complaints book contained a number of new entries that had been made since the schemes last inspection. One concern related to the use of so called ’inappropriate’ language by staff. The manager said she had dealt with this matter at the time, although conceded that she had failed to record the action taken in response outcome of the subsequent investigation and action taken in response. The complaints book also contained a number of entries that could not be classified as either a complaint or concern, but were in fact ‘significant’ incidents involving occupants, which mainly pertained to falls. While the manager is commended for ensuring all incidents and complaints/concerns are recorded, logging them all in the one single source document is not considered ‘best’ practice. For ease of referencing purposes all complaints made about the schemes operation should be logged separately from any significant incidents that occur. Furthermore, the schemes complaints procedure needs to be updated to include the name, address and telephone number of the CSCI. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 16 It was positively noted that senior managers representing Scope had established a number of risk management strategies to help staff and occupants deal with one of the schemes immediate neighbours, and in doing so improve relations between them. Several meetings were arranged by Scope to get all the interested parties and other relevant professional agencies to talk about any ‘concerns’ they had and a set of clear guidelines agreed for all to follow. According to the manager the new arrangements are working well and there have been no repeats of the ‘unsavoury’ incidents that occurred in October 2005 between the schemes immediate neighbour and staff. It was also evident from the schemes communication book that the immediate neighbour is adhering to guidelines set down at the aforementioned meetings and now only requests to speak directly with the schemes manager. A couple of the occupants met during this inspection said that overall staff were good listeners and were always on hand to offer them advice and support about any concerns or complaints they may have. The Commission has received one allegation of abuse made within the scheme since it was last inspected. In accordance with the Local Authorities vulnerable adult and Data protection protocols this highly sensitive and confidential information was shared with all the relevant parties, including the Scope manager and Croydon Social Services vulnerable adult protection team. A number of strategy meetings were held over the telephone with all the relevant professionals involved and it was agreed that the most appropriate course of action to take would be to allow Scope to carry out its own internal investigation into these allegations of abuse. It was positively noted that Scope suspended the member of staff concerned without prejudice from working alone with the occupants or carrying out any personal care duties while the matter was investigated. During the course of this inspection it was confirmed that these interim arrangements were being adhered too by the scheme. The occupant who alleges a member of staff abused them said senior managers from Scope have now interviewed them and everyone concerned is confident that the investigation will be concluded by the end of January 2006. The manager said that all the interested parties, including the occupant and staff member involved, as well as the Commission, would all be notified as soon as practicable. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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): 24, 27, 28 & 30 The size and layout of the self-contained flats, which are all suitably adapted to meet the occupant’s physical needs, ensures they all live in a relatively homely, comfortable and safe environment that maximises independence. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 18 EVIDENCE: There have been no significant environmental changes made to the scheme since its last inspection in Septermber‘05. The general consensus of opinion expressed by all the occupants met was that their kitchen units, although functional, had all seen ‘better days’ and could probably do with up dating. Therefore, it was positively noted that as recommended in the schemes last report Scope had looked into the possibility of refurbishing a number of the occupant’s kitchens and the manager was confident that work would begin on in April ’06. Progress on this matter will be assessed at the schemes next inspection. Having tested the temperature of hot water emanating from a tap attached to the bath in Flat No#9 it was found to be a safe 40 degrees Celsius at 12.40. The manager said that all the schemes water outlets have been fitted with preset tamper proof and fail safe thermostatic mixer valves. Flat No#3 has been fitted with a new shower, which the occupant of this flat indicated they found useful. A couple of staff members spoken with at length said the staff sleep-in room can get rather chilly at night during the winter and the situation was compounded by the fact that the office/sleep-in room door and windows had only been fitted with single pane glass. The wooden frames surrounding these particular windows and door also looked a little rotten and it is therefore recommended that a time specific programme to replace them be drawn up. Each of the occupants flats have been provided with washing machines with hand washing facilities prominently sited. The scheme has appropriate infection control procedures in place to minimise the cross and spreading of diseases. The scheme has a contract with the Local Authority for dealing with clinical waste on a weekly basis. A member of staff on duty during the early shift was observed putting on protective gloves and an apron before going off to support an occupant with their personal care needs, in accordance with good infection control guidelines. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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, 35 & 36 Sufficient numbers of suitably experienced and competent staff are employed to meet the health and welfare needs of the occupants. However, not all staff are receiving at least one supervision session with a suitably qualified senior every two months. This shortfall may have an adverse affect on the standard of care the occupants receive from members of staff who are not being apparently supervised and supported by their line manager. These comments notwithstanding, the schemes arrangements for recruiting new members of staff are sufficiently robust to ensure, so far as reasonably practicable, individuals who are ‘unfit’ to work vulnerable adults are not employed. EVIDENCE: The manager stated that just over 50 of the schemes staff team have already achieved a National Vocational Qualification in care (level 2 or above), in line with Governments current training targets for care workers, and that two others were hoping to be awarded theirs by the end of the year (2006). Scope evidently remain committed to the aim of having 100 of its care staff team qualified to NVQ level and are commended for having such a positive approach to staff training in general. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 20 There have been no changes to staffing levels since the schemes last inspection. Two members of the schemes care staff team, the manager, and a care worker temporarily assigned office based work, were all on duty at the time of arrival. The manager was adamant that the numbers of staff on duty were adequate to meet the assessed needs of the occupants currently residing at Blake Court, although she was very conscious that certain occupants needs had altered so significantly in recent months that the schemes current staffing levels may need to be reviewed if all other arrangements remained unchanged. Staff turnover in the past six months has remained relatively low. The manager has not recruited any new members of staff since September ‘05, although the manager has recently interviewed two new members of staff to fill the schemes vacant posts. Both new staff have worked at Blake Court before on the agency. The manager is commended for ensuring these two new members of staff will not been confirmed in post until Scope has received satisfactory Criminal Records Bureau checks in respect of these individuals and for ensuring the occupants receive continuity of care from individuals they are already familiar with. The manager conceded that despite it being recommended in the schemes previous inspection report she had not asked the schemes new temporary agency/bank workers to sign and date a record to say they had received and understood their initial induction, unlike staff employed on a permanent basis. This good practice recommendation is repeated at the end of this report for the manager to re-consider introducing. Staff training was not assessed in any great depth on this occasion and will therefore be inspected at the schemes next visit. The manager said that the vast majority of the staff team attended an infection control course in October 2005. It was positively noted that both the manager and another senior member of staff had attended a supervision-training course, as required in the schemes last report. The manager is confident that between the two of them they will be able to ensure all the schemes staff receive an annual appraisal by 1st April 2006. These comments notwithstanding, it was nevertheless disappointing to note that despite recent reminders, two staff files inspected at random revealed that neither of them had received a formal supervision session with a suitably qualified senior since July 2005. The manager confessed to being a little confused about the frequency of these sessions and is reminded once again that all staff must receive at least one formal supervision session every two months and to keep appropriate records of these meetings. Now the manager and a senior are suitably qualified to undertake staff supervision the scheme should have very little difficulty achieving the aforementioned objective. Progress on this matter will be assessed at the schemes next inspection. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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, 38, 39 & 42 In the main the schemes health, safety and fire arrangements appear to be sufficiently robust to protect the occupants, their guests and staff from avoidable harm. Scope still needs to carry out an annual audit of the scheme and ascertain the views of all the relevant stakeholders of the service, including those of the occupants and their representatives. Without such an effective quality assurance system in place neither the service providers nor the manager will be able to effectively measure how successful they have been at achieving the schemes stated aims and objectives. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 22 EVIDENCE: The schemes manager, Carol Jones, has been in operational day-to-day control of Blake’s Court for the past two and a half years. Carol says she has been experiencing on going problems with the National Vocational Qualification level 4 training course she attends and the organisation that runs it have advised her that they are no longer able to assess her work. The manager has now enrolled on another NVQ course, which she hopes to start in February 2006. Carol is confident she will have completed the necessary management training by the end of 2006. Progress on this matter will be assessed at the schemes next inspection. As mentioned throughout this report Blake Court has experienced a number of significance incidents and events in 2005 and it was clear from comments made by the manager that she personally feels very supported by her line manager and Scope in general. Staff arriving for the late shift confirmed that the schemes next staff meeting was set to take on Thursday 5th January 2006 a month since the last one. Staff spoken with said these meetings were useful forms for discussing service users needs, especially a so many had significantly altered in recent months. The manager conceded that she was not aware of any stakeholder survey’s that had been undertaken by Scope in the past twelve months as part of their professionally recognised system to assure quality of care. Without this in place the service providers and manager will be unable to effectively measure how successful or not they have been in achieving the schemes stated aims and objectives. This process of self-monitoring must be continuous and the results of service users/stakeholder surveys/questionnaires must be published and made available to all interested parties, including service users, their representatives and the CSCI. Up to date Certificates of worthiness were in place as evidence that ‘suitably’ qualified professionals had carried out periodic checks in respect of the schemes fire alarms system and extinguishers and over head mobile tracking system in the past twelve months. The schemes emergency lighting was also tested in May’05, fire alarms checked by staff on a weekly basis and the last fire drill undertaken by all staff on duty on 12th December 2005. The schemes fire safety risk assessment of the premises has also been reviewed in the past year in accordance with fire safety regulations. Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Blake Court Score X 3 X X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X 3 X DS0000025756.V273724.R01.S.doc Version 5.0 Page 24 NO 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 YA9 Regulation 13(4) Requirement Risk assessments detailing all the action to be taken by staff to minimise the occurrence of any identified risks must be included on each occupants care plan. A record of all the action taken, if any, in response to a complaint made about the schemes operation must always be appropriately maintained by staff. All complaints made about the schemes operation must be entered into a separate complaints log and similarly all the significant incidents that may occur at the scheme must also be recorded in a separate source. Copies of the schemes complaints procedure must include the name, address and telephone number of the Commission. All staffs job performance must be appraised at least once a year by the schemes manager and DS0000025756.V273724.R01.S.doc Timescale for action 01/02/06 2. YA22 17(2), Sch 4.11 15/01/06 3. YA22 17.2,sch 4.11 15/01/06 4. YA22 22(7) 01/02/06 5. YA36 18(2) 01/04/06 Blake Court Version 5.0 Page 25 appropriate records kept. 6. YA36 18(2) All staff must receive a formal supervision session with a suitably qualified senior at least once every two months and appropriate records kept. An effective quality assurance system must be introduced and the results of any service user/stakeholders holder surveys/questionnaires undertaken published. 01/01/06 7. YA39 12(3) & 24 01/04/06 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. Refer to Standard YA19 Good Practice Recommendations A copy of the needs assessment undertaken by a suitably qualified occupational therapist in respect of one of the schemes occupants whose needs have significantly altered in recent months should be forwarded to the Commission. The windows and door in the office/staff sleep-in room should be replaced. Agency/bank staff who have never worked at the scheme before should sign and date a record as proof that they have understood the contents of their initial induction. This recommendation was previously issued on 22nd September, but was not considered. The manager should have completed the management component of her NVQ Level 4 in training in care by the end of 2006. Previous timescale for action of 1st January 2006 not met. 2. 3. YA28 YA35 4. YA37 Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Blake Court DS0000025756.V273724.R01.S.doc Version 5.0 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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