Inspection on 24/05/06 for Blossom Place

This inspection was carried out on 24th May 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blossom Place 04/06/07

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Blossom Place 24 Allenby Road West Thamesmead London SE28 0BN Lead Inspector Maria Kinson Unannounced Inspection 24th May 2006 10:30 Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 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 Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 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. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Blossom Place Address 24 Allenby Road West Thamesmead London SE28 0BN 020 8312 2333 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) The Olive Services Ltd Mrs Olufunke Ogunleye Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Blossom Place is registered by The Commission for Social Care Inspection to provide personal care for fourteen male or female service users, aged 18 to 65 years of age. The home aims to provide holistic care for service users with a mental health disorder that require a period of rehabilitation or treatment. The home is located in a small cul de sac, on a new housing estate, on the borders of Plumstead, Thamesmead and Woolwich. The home is within walking distance of a mainline railway station, local bus routes and shops. The home consists of two, two-storey houses (House A and B) and a detached house, which staff referred to as the activity block. All of the bedrooms are single occupancy, fully furnished and have an en suite shower and toilet. The activity block includes a computer suite, office space, meeting rooms and a kitchen. All of the service users living in the home have use of the laundry area, which is located between house B, and the activity block. There are four parking bays at the front of the home. The fees charged by the home range from £850 - £1000 per week. This information was provided for the commission on 26.07.06. Service users were responsible for meeting additional costs that were not included in the fee such as hairdressing and transport charges. Further information about this home can be obtained by requesting a copy of the Statement of Purpose or visiting www.oliveservices.com Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of this service. Blossom Place was registered by the Commission for Social Care Inspection in December 2005. This inspection took place on 24.05.06 between 10:30am and 17:30pm and on 01.06.06 between 13:05pm and 18:15pm. The inspector viewed all of the communal areas and a sample of bedrooms. Care, recruitment and health and safety records were examined and the handover from morning to evening staff was observed. Comment cards were sent to relatives and health and social care professionals that were in regular contact with the home. Twelve cards were returned to the commission. There were six service users living in the home at the time of the inspection. What the service does well: The manager and staff had worked hard since the home opened to ensure compliance with The Care Homes Regulations and National Minimum Standards. All of the standards assessed during this inspection were met or almost met. The arrangements for assessing prospective service users needs were good and service users had an opportunity to visit or stay in the home prior to making a decision to move in. Staff developed an individual support plan for each service user. The plan was prepared in consultation with the service user and covered all aspects of their life such as health, social and personal care needs. A separate risk assessment was undertaken and kept on the front of each file. Staff supported service users to maintain active and fulfilling lifestyles based on their personal interests and goals. Service users were supported to learn new skills, improve their existing skills or attend work placements where possible. The staff team was stable. Service users received support from familiar staff that understood their needs and the level of support they required. Staff said they enjoyed working in the home and were satisfied with training opportunities and supervision arrangements. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 6 The service was managed by a competent manager that worked tirelessly to provide a good standard of support for service users. The manager had introduced systems to prompt service users to attend appointments and ensured that adequate support was provided for service users in the community. Complaints were investigated promptly and good communication was maintained with the complainant. What has improved since the last inspection? What they could do better: This home has only been registered for six months. Most of the standards assessed were met or almost met. The main weaknesses related to medication, health and safety and staff recruitment records. The manager has the capacity and skill to address these issues. Clear information must be provided for prospective service users and Care Managers about the type of care provided in the home. The contract should set out in detail what is included in the fee, the role of the provider and the rights and obligations of the service user. Staff must ensure that accurate and update records are maintained for all medication received in the home and sent for disposal. The menu should reflect the full range of food provided for service users. To promote service user independence and autonomy service users should be provided with a key to their room and the home. Staff may have to consider how they can reduce the risk of service users loosing keys by providing key rings that can be attached to clothing or other suitable devices. The Registered Person must ensure that the environment is adapted where necessary to meet service users needs. The manager and senior staff must undertake thorough checks when recruiting new staff. This will provide greater protection for service users. The home was well maintained but regular in house checks must be undertaken to identify health and safety issues. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 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. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 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 Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose provided useful information about the service but did not provide clear guidance for the reader about whether the home provided personal or nursing care. The arrangements for assessing and admitting new people into the home were good. EVIDENCE: The manager supplied the commission with an up to date copy of the Statement of Purpose and Service User Guide for the home. Both documents provided useful information about the service but the Statement of Purpose did not include all of the information listed in the Care Homes Regulations. It was not clear to the reader whether the home provides personal or nursing care, as registered mental health nurses were listed under staffing and the document did not indicate that nursing care was not provided. See requirement 1. The arrangements for admitting new service users into the home were good. Once a formal referral was received the manager of the home or a senior member of staff visit the prospective service user to undertake an assessment and discuss their needs. Information such as reports and assessments were obtained from other professionals who had been involved with the service Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 10 users care. If the assessment indicates that the home is suitable for meeting the persons needs the service user was invited to visit the home to meet staff and service users. Visits can be arranged at a time to suit the service user and if appropriate service users can stay overnight or spend a weekend in the home. Following the assessment the manager writes to the service users Care Manager to confirm that the home can meet their client’s needs. To comply with regulations a copy of this letter must also be sent to the service user. All of the service users that responded to the comment cards sent out by the commission had received a contract. Some information such as the period of notice was not included in the contracts kept in service users files. See recommendation 1. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users assessed needs and personal goals were reflected in their individual plans. Service users were encouraged to make decisions about their care and welfare. EVIDENCE: Two sets of records were examined. Both of the files included comprehensive care plans, which outlined how service users individual needs were to be met and information about personal preferences and goals. Potential and actual risks to service users and others were assessed before admission and strategies to reduce or manage risk were clearly recorded. Staff should ensure that all documents including risk assessments include a review date. All of the documentation seen was up to date, legible and had been reviewed at regular intervals. Service users were encouraged to contribute to support plans and attend review meetings. The standard of documentation maintained in the home was good. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 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, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were encouraged and supported to lead active and fulfilling lives. The food provided in the home met service users needs and tastes. EVIDENCE: The home employs a part time activities coordinator who visits the home three times a week to prepare an activity programme and provide one to one support for service users. Support staff were responsible for facilitating the sessions listed on the programme. The programme included arts and crafts; nail care, games and computer skills. Service users confirmed that regular activities were taking place in the home but said that some of the sessions listed such as baking and bowling were not provided. Individual activity plans were prepared in consultation with service users. Activity programmes were based on service users personal interests and goals and incorporated practical skills such money management. Arrangements had been made for one service user to attend local education classes to improve their literacy and numeracy Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 13 skills and another service user was supported to prepare and cook some meals. The home has a computer room with internet access for service users use and was starting to develop a library. All of the service users were invited to a weekly meeting. The meeting provided an opportunity for service users to discuss issues of concern or ideas for improving the service. One service user said staff listened to the comments he made during meetings and said he was able to speak freely. The manager had asked service users to take more responsibility for leading the meetings by preparing their own agenda and producing the minutes. One service user had agreed to take on this role. The minutes for the last meeting were seen. Service users that attended had requested specific food and drink for the planned BBQ and one service user had agreed to organise the music. One service user had expressed concerns about an incident that occurred in the home. It was apparent from the records that the manager was taking the service users comments seriously and had started to investigate the matter. Service users were allocated one to one time with their key worker each week. Some of the service users used this time as an opportunity to go out shopping, or were supported to improve their independent living skills in the home. Service users were encouraged to contribute to the running of the home by assisting with household chores such as cooking, cleaning and maintaining the garden. Service users were able to maintain contact with friends and family via the telephone or could receive visitors in the home. The manager said that relatives would be invited to support meetings and social events. Written and verbal feedback about the service was obtained from two relatives. Both were satisfied with the visiting arrangements, said they were kept informed about important matters and were satisfied with the overall care provided in the home. None of the service users had a key to their bedroom or the front door of the home. This issue was discussed with the manager who agreed that keys would be provided for service users, subject to a risk assessment. The arrangements for replacing lost keys should be discussed and agreed with service users. See recommendation 2. The home employs a part time cook who prepares the main meal and an evening snack three days a week. On the other days support staff and service users prepare meals. The menu included a good variety of English and Jamaican dishes but provided little choice. Discussion with the manager indicated that fresh fruit, juice and other meals were available on request but were not included on the menu. The manager should ensure that the menu reflects the full range and choice of food provided for service users. See recommendation 3. Service users told the inspector that the food provided in the home was good. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 14 Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users received support to maintain good physical and mental health. The home did not maintain adequate medication records. This issue could compromise service users health and safety. EVIDENCE: Feedback was obtained from six health and social care professionals that were in regular contact with, or had visited the home in recent months. The feedback received was mostly good with all of the respondents stating that that they were satisfied with the overall care provided in the home. Two respondents expressed concerns about the cost of the service and said there was a “lack of specialist staff such as an Occupational Therapist and Psychologist”. Feedback from the remaining professionals was good, one professional provided additional information about the manager who they said had “addressed my clients changing needs promptly and has sought specialist help where necessary”. The manager had good knowledge of local mental health services and support groups, which she encouraged or referred service users to where appropriate. Four service users were registered with a local GP and the remaining service Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 16 users will be referred to a local GP once the trial period has expired and the placement is made permanent. Service users were supported to attend GP and hospital appointments if necessary. Service users were encouraged to tell staff about signs that suggested their health might be deteriorating. This information was recorded in service users care plans and was known to staff. This home is registered to provide personal care. Some of the care plans viewed made reference to staff nurses. There was some evidence that some members of staff were providing nursing care by assessing and dressing wounds and administering rectal medication. This issue was discussed with the manager. Evidence was seen during the second day of the inspection that indicated that this aspect of care had been handed back to the District Nurses. See standard 1 re Statement of Purpose. Assistance with personal hygiene was provided where necessary. Service users said they were able to decide for themselves when they got up and how they spent their time. The staffing arrangements and designated key worker system provided good continuity of support for service users. The management of medication was variable. Storage facilities were good with internal and external medicines stored separately. Although the medication room felt cool there were no temperature records to ensure that the temperature was suitable for the storage of medicines. There were no records of receipt or disposal of medication. The manager agreed to amend the medication administration chart to include this information. Records of administration of medicines were good. Some staff had attended medication training provided by the supplying Pharmacist and were currently undertaking a period of practical training and a competency based assessment. Some of the text on the medication sheets did not line up properly. This issue should be resolved as it could increase the risk of errors. See requirement 2. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had good systems in place to respond to concerns and complaints. EVIDENCE: The home provided each service user with a copy of the complaints procedure and a simple flow chart to show the stages that a complainant can follow if they are dissatisfied with the response provided by the manager. The procedure included information about the timescale for investigating complaints and contact details for the commission. The accompanying flow chart indicated that complainants could contact PALS (the patient advisory liaison service) if they were not satisfied with the response provided by the home. This service is provided for people using NHS services. See recommendation 4. The home had received one complaint concerning staff communication. The records indicated the matter was investigated promptly and written feedback was sent to the complainant. The home had an adult protection procedure, which indicated that Social Services, CSCI and the Police would be notified about allegations of abuse. The manager had made contact with the Adult Protection Coordinator in Greenwich to request a copy of the local authority procedure. Staff that the inspector spoke with had a good understanding of abuse and knew what action to take if they were advised about or witnessed abuse in the home. Staff had discussed the homes whistle blowing policy during a recent staff meeting. The Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 18 manager had attended adult protection training in her previous job and training for the remaining staff was planned. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 19 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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean and comfortable environment for service users and their visitors. Some adaptations to promote independence and assist rehabilitation were not provided for service users with physical disabilities. EVIDENCE: The home consists of two separate houses each with a shared lounge, conservatory, kitchen and dining area. The home and grounds were well maintained and in good decorative order. All areas were bright, clean and tidy. Staff from the local environmental health team had inspected the main kitchen in April 2006. No requirements were made as a result of this visit but verbal advice was provided. All of the bedrooms in the home are single occupancy with en suite shower and toilet facilities. Good quality furniture was provided and some of the service users had brought their own furniture, computers or televisions with them Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 20 making their rooms appear more homely and welcoming. Specialist furniture and fittings had been purchased to maintain service users safety where possible. Although most of the service users spoken with said they would prefer to live in their own home they did agree that the home was comfortable and particularly liked having a garden where they could relax during the summer months. The manager said plans were in place to plant flowers and shrubs in the garden and purchase garden seating. Specialist equipment was provided for one of the service users with complex health care needs. This service user required assistance to move around some parts of the home, as there were no ramps. The manager said that quotes had been obtained to fit ramps in some parts of the home. This work must be undertaken promptly. See requirement 3. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a stable team of staff that provide consistent support for service users. Staff had access to vocational and ongoing training. Staff recruitment practices were variable. Staff must ensure that robust procedures are followed to protect service users. EVIDENCE: When the inspector arrived in the home the manager and three support staff were on duty. Staffing rosters indicated that there were at least two support staff on duty during daytime shifts and three support staff on duty overnight. The manager worked Monday to Friday but was working additional hours to provide support for staff, as the home was new. The manager was able to adjust staffing levels to meet service users needs during periods of high activity or to facilitate support for service users in the community. In addition to the staff highlighted above the home employs a part time deputy manager, cook, cleaner and activity coordinator. Routine maintenance work was undertaken by one of the directors but staff were also able to telephone local contractors for urgent issues. The home has access to Psychology input but this service is was not included in the fee. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 22 Two care staff had a vocational qualification in care and four staff were undertaking this training. The home was actively working toward meeting the standard set by the Department of Health for 50 of staff to achieve this qualification. Induction training was provided for new staff. A copy of the attendance sheet for a one day induction training course was seen but records of individual staff induction training could not be assessed as they were held by staff. See recommendation 5. Since the home opened some staff had received food hygiene, first aid, medication and mental health awareness training. A training programme had been developed for 2006 which, included health and safety updates, adult protection, medication and substance abuse. The Registered Person should ensure that ongoing training is provided for staff about relevant mental health issues. Three staff recruitment files were examined. Some of the files did not include all of the information required by regulation. One file had a criminal record disclosure from a previous employer and one reference. Some of the references provided were not from the previous employer and there was little evidence to show that the provider had taken steps to ensure that the references were authentic. Some of the photographs provided were not very clear as they were photocopied from passports and other documents. A statement from the employee about their physical and mental health could not be located in one of the files. See requirement 4. Staff said that they felt supported by senior staff and the manager. An on call system was used for advice or to inform senior staff about significant issues. Regular staff meetings were held in the home and minutes were taken as a record of the issues discussed. Staff were seen interacting with service users in a professional and courteous manner. Written and verbal feedback was obtained from five service users. The majority of service users were satisfied with the information and support they received in the home, said that staff usually listened to their views and were available when they required assistance. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This home was well managed and led. The atmosphere in the home was open and supportive. Some health and safety concerns were identified but the manager indicated these issues would be addressed promptly. A quality assurance system was being introduced but this work was not well established as the home had only been opened for a short period. EVIDENCE: The manager of the home was assessed by the commission as a ‘fit’ and suitable person to manage a care home for people with a mental health disorder. The manager has many years experience of working in community and acute mental health services and had completed training relevant to this post. The manager has a degree in education, is a Registered Mental Health Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 24 Nurse and has a Post Graduate Diploma in Counselling. The manager advised the inspector that she is currently undertaking the registered managers award. The home was well organised and run. Record keeping was mostly good. Accident and incident reports were legible and provided a factual account of issues that had occurred in the home. The home had a set of policies and procedures to guide staff. The manager had arranged for staff to discuss some policies during staff meetings and supervision. The manager should ensure that all policies are signed and dated. Health and safety issues were mostly good but there were no records of in house safety checks except fire alarm tests. It is recommended that hot water temperatures, portable electrical appliances and window restrictors are checked on a regular basis and fire drills and emergency lighting tests are undertaken and recorded at regular intervals. The home had completed a fire safety risk assessment and seven staff had attended fire safety training. Certificates to confirm gas appliances and the mains electricity installation were safe were forwarded to the inspector. Records of service visits for the fire alarm, emergency lighting and extinguishers were valid but were due for renewal in July 2006. Some of the radiators felt very hot to touch. The Registered Person must risk assess this issue and take action to reduce the risk of burns or scalds. See requirement 5 and 6. This service has only been operating for approximately six months so quality assurance systems were still being introduced. Feedback about the service was obtained from service users during the weekly meeting and from other professionals and relatives when they made contact with the home. The responsible person was undertaking regular unannounced visits to the home. The manager advised the inspector that medication checks and a documentation audit had been carried out but the results from the audit were not available to view during this inspection. The home must ensure that all quality assurance work is recorded and plans to address issues identified are reviewed. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 25 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 2 2 3 3 X 4 3 5 2 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 3 26 3 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Not applicable 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 YA1 Regulation 4 Requirement Timescale for action 06/09/06 2. YA20 13 The Registered Person must ensure that the Statement of Purpose includes the following information: • The relevant qualifications of staff • The organisational structure of the care home • Whether the home provides nursing care • The size of rooms in the care home A copy of the revised Statement of Purpose must be supplied to the commission within 28 days of any changes being made. The Registered Person must 09/08/06 ensure that: • Adequate records are maintained for all medicines received in the home • Adequate records are maintained for all medicines disposed of by the home • The temperature in the medicine room is monitored and recorded • That information on DS0000061203.V291429.R01.S.doc Version 5.1 Blossom Place Page 27 3. YA29 23 4. YA34 19 5. YA42 13 6. YA42 23 administration charts lines up and is easy to follow The Registered Person must ensure that suitable adaptations to meet service users needs are provided. The Registered Person must not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in Schedule 2. Information and documents missing from existing staff files must be obtained. The Registered Person must: • Test the emergency lighting on a regular basis • Carry out a risk assessment and implement strategies to reduce the risk of burns and scalds from radiators and hot water outlets • Carry out a risk assessment and implement strategies to reduce the risk of falls from windows • Carry out a visual inspection of portable electrical appliances The Registered Person must ensure that staff and service users are aware of the procedure to be followed in the event of a fire. This includes regular fire drills. 30/10/06 09/08/06 09/08/06 09/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000061203.V291429.R01.S.doc Version 5.1 Page 28 Blossom Place 1. 2. Standard YA5 YA16 3. 4. 5. YA17 YA22 YA35 The Registered Person should ensure that contracts include all of the information listed in standard 5.2 of the National Minimum Standards for Adults. The Registered Person should ensure that service users are offered a key to their own room and a key to the front door of the home, subject to restrictions agreed in the support plan. The Registered Person should ensure that the menu reflects the full range of food provided for service users. The Registered Person should ensure that the complaint flow chart provides accurate information for service users. The Registered Person should ensure that staff induction training records are kept in the home. Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Blossom Place DS0000061203.V291429.R01.S.doc Version 5.1 Page 30 - 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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