Inspection on 17/10/06 for Crescent Dale

This inspection was carried out on 17th October 2006.

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

The inspector found 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

Crescent Dale 27/06/07

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Crescent Dale 2 Nunroyd Heckmondwike WF16 9HB Lead Inspector Tracey South Unannounced Inspection 17th October 2006 02:00 Crescent Dale DS0000067158.V310597.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 Crescent Dale DS0000067158.V310597.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. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crescent Dale Address 2 Nunroyd Heckmondwike WF16 9HB 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) 01924 325671 01924 325674 www.kirklees.gov.uk Kirklees MC Mrs Tania J Webb Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/a Brief Description of the Service: Crescent Dale is owned and managed by Kirklees Metropolitan Council and provides a service to younger adults with a learning disability. The home is situated near to the town centre of Heckmondwike. The home is on a bus route for Heckmondwike, Dewsbury and Batley. The nearest train station is in Dewsbury. Crescent Dale is a single storey building. There are two communal lounge areas, two dining rooms, one of which has a kitchenette. Other facilities include a large kitchen, two offices, a laundry room and a sensory room. The building is surrounded by large gardens and patio areas. Crescent Dale benefits from having a hearing loop installed, to assist those people with hearing problems. Crescent Dale is a no smoking house. Information provided by the home prior to the inspection indicated that the fees range from £334.79 to £1,043.78 per week. Additional services and items not included in the fees include daily newspapers, hairdressing, alcoholic drinks, toiletries and shaving items, cigarettes and tobacco, clothing, stationary and writing materials, outings, confectionery, dry cleaning, transport to appointments not paid for by the NHS or Local Authority, postage stamps, private telephone calls. The service provider ensures that information about the service is available to prospective service users and the current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to take place at Crescent Dale. The home was registered with the Commission for Social Care Inspection in April 2006. As part of this key inspection the Commission for Social Care Inspection (CSCI) undertook a visit to the home. Alongside this, the staff at the home also completed a pre-inspection questionnaire, which was returned to the Commission before the inspection as requested. Information from this questionnaire was also used for this report. To make sure that the manager was at the home, a couple of day’s notice of the visit was given. The inspector arrived at the home at 2.05pm and left at 9.20pm. Surveys were sent to service users, their relatives, visiting professionals and GPs. No surveys were returned to the Commission. In writing this report, information and evidence was not only obtained by way of visiting the home, but information and evidence was obtained from notifications sent to and information obtained by Commission for Social Care Inspection. Whilst at the home, key documents such as care records, care plans, daily records and some of the home’s policies were looked at. A tour of the home was also undertaken. Three members of staff were spoken with, along with the manager. The inspector spoke with two service users. There were eight service users living at the home on the day of the inspection. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: Prospective service users are thoroughly assessed prior to them moving into the home. They are able to visit the home and meet with the staff before they make a decision about moving in. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 6 Each person has a care plan in place, which clearly sets out their needs and the level of support they require from staff. Service users are encouraged to take part in the drawing up of their care plan. Reviews take place on a regular basis and any changes in the person’s needs is clearly written down. Service users are able to choose the activities they wish to join in. Service users are involved in developing menus. Crescent Dale offers meals that are well balanced and healthy. Specialist diets are also catered for. Staff are respectful of service users’ rights to privacy and dignity. What has improved since the last inspection? This is the first inspection to take place at Crescent Dale. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 7 What they could do better: Service users are not being offered the opportunity to take holidays. The staff must be creative in thinking of ways to enable service users to choose and plan holidays outside the home. The majority of staff require infection control training to assist them with their jobs. All staff must be involved in a fire drill at least twice a year. 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. Crescent Dale DS0000067158.V310597.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 Crescent Dale DS0000067158.V310597.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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users’ individual needs are assessed prior to them moving into the home. EVIDENCE: There was good evidence within the care records to confirm that prospective service users are thoroughly assessed prior to them moving into the home. It was clear from discussions with the manager that admissions to the home only take place if she feels confident that the staff have the skills, ability and competencies to meet the assessed needs of the prospective service user. For example, a recent admission was delayed, as the care staff required specific training prior to the person moving in. Without the training there was no guarantee that the staff were able to understand and meet the service users’ health care needs. None of the service users currently living at the home are self-funding and therefore their placements have been arranged through social services. There was evidence that Community Care Assessments had been received prior to the person moving in to the home. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Services users’ assessed and changing needs and personal goals are reflected in their care plan. Service users make decisions about their lives with assistance as needed. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The two care plans examined were of a good standard. It was clear that the information provided in the community care assessment had been used to form the basis of the initial care plan. The care plans examined focused on the individual’s needs such as sensory, sleep, nutrition, mobility, medication, choices, social skills, health as well as identified risks. Each care plan gave comprehensive details about the person’s needs including the level of support they required. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 11 The manager explained that care plans are drawn up with the involvement of the service users where this is appropriate. One recently admitted service user had initialled his care plan to demonstrate his involvement in the process. Care plans are reviewed on a regular basis. Amendments are made when the needs of the service user changes. There was good evidence of this in respect of one service user whose health has deteriorated rapidly over the past few months. There was good evidence to demonstrate that staff do support service users in making their own decisions. Staff explained how one service user who previously enjoyed going out during the day has, since the move to Crescent Dale, become anxious about leaving the home. The service user is supported by staff in his decision not to go out, but at the same time they will continue to encourage him to undertake such outings when the time is right for him. Service users who are able to manage their own finances are encouraged to do so. Care plans include comprehensive risk assessments. One care plan contained a number of identified risks. The information recorded was easy to follow and clearly outlined the level of risk and the measures in place to minimise the risk and any associated hazards. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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 are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. 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. EVIDENCE: The majority of service users at Crescent Dale are over the age of 60 years, and none are currently in any form of employment. However they do join in community based activities. Most service users attend Ravensthorpe resource centre and a couple attend Branches. Staff explained that the move from Dewsbury to Heckmondwike has been beneficial in terms of accessing local community services. The home is situated near to local amenities and easy accessible in terms of public Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 13 transport. The manager explained that some residents are able to walk into Heckmondwike, accompanied by staff. The manager spoke of how she is hoping to introduce new rotas to accommodate one to one time spent with service users. Each service user has been allocated a link worker. It is anticipated, with the introduction of new rotas, each link person will have time set aside for them to undertake some sort of activity with their service user. This may include an outing or time spent in the home on an individual basis. One service user who spoke to the inspector explained how she would like to go on a holiday to Blackpool but is unable to do so. The staff explained that there is a dispute between the trade unions and KMC regarding staff pay when escorting service users on holidays. Staff explained that this issue has been ongoing for a considerable length of time and meanwhile service users are unable to go on holiday. This particular service user and her relative are bitterly disappointed, as she has always enjoyed her holidays in the past. The CSCI would urge the local authority and the trade unions to resolve the matter as quickly as possible. In the meantime the manager should explore other means as to service users being able to take holidays. Service users are encouraged to spend time with their relatives and friends. Visitors are welcome to the home at any reasonable time. Some service users prefer to go out and visit their relatives. There was evidence of this in the case records examined. Staff respect the private space of service users and were observed knocking before entering bedrooms. The majority of staff have worked with the service users for a number of years and it is clear when speaking to staff that they have a very good understanding of the needs of people living at the home. Service users are encouraged to take part in daily routines such as cleaning and preparing light snacks. Some service users enjoy undertaking laundry duties assisted by staff. The manager explained that service users have had input in developing menus. The cook has spent time with individual service users establishing their likes and dislikes. Specialist diets, such as diabetic, high calorie, low fat and soft diets are catered for. The speech and language therapist is involved with individual service users in accordance with their nutritional needs. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional needs are met. The home has effective medication systems in place. EVIDENCE: A number of the service users living at Crescent Dale require assistance with their personal care needs. This is carried out in a sensitive manner, maintaining privacy and dignity is high priority for the staff. People’s preferences in respect of how they wish their personal care needs to be met are clearly set out in the care plan. Those service users who are able to support themselves are encouraged to maintain their own independence. There was good evidence in the care plans examined that service users have access to health care services. The manager explained that the home is fortunate in being able to access health services from the resource unit based at Dewsbury. All service users are registered with a local GP; home visits are arranged for those people who are unable to attend the surgery. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 15 The home operates a safe and effective medication system. The co-ordinators and night staff are responsible for administering service users’ medication. The medical records of two service users were looked at, both of which were up to date, neat and tidy and easy to follow. Medication supplies tallied with the records held. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 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 complaints procedure that is clear and easy to follow. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints procedure is produced by Kirklees Metropolitan Council. There is a written procedure, which is clear and easy to understand. The procedure is also available in CD format as well as other languages, upon request. The procedure is displayed in the front entrance of the home. Service users are also informed of the procedure with the home’s statement of purpose and service user guide. The home has received one complaint since opening in April 2006. The complaint was dealt with in an appropriate manner, and within the timescales, as referred to in the complaints procedure. Records of all complaints, including concerns and compliments are kept. The information recorded includes the action taken to resolve the complaint. The manager has recently written to all service users’ relatives reminding them of the procedure. Staff explained how they are able to identify when service users are concerned about things, this is mainly down to the fact that they have know them for a number of years and can sense when something isn’t right. This has been Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 17 enhanced further with the introduction of link workers and the close relationship they share with service users. In most cases the staff will act as advocate for the service user and will act on their behalf when they are unhappy or worried about things. The manager has a good understanding of adult protection matters and is clear about her responsibility of dealing with allegations of abuse. When examining staff records it was noted that the majority of staff have not received refresher training in respect of adult protection for over 12 months. As Kirklees Metropolitan Council have recently launched a new adult protection procedure, it is recommended refresher training be provided to all staff, as applicable. Crescent Dale DS0000067158.V310597.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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users live in a homely, and comfortable environment. clean and hygienic. EVIDENCE: Crescent Dale is a new building and the décor of the home is of a very high standard. The quality of the fixtures and fittings are of a high quality creating a homely and comfortable environment for service users. The home offers access to local amenities, local transport and relevant support services. The staff explained how they often go into Heckmondwike for the weekly shop. The premises are in keeping with the local community. The building has a highly efficient fire alarm and sprinkler system installed. The home operates a “stay put” policy in the event of fire. This means that the staff and service users will not evacuate the building should a fire occur. Each Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 19 The home is service user has a risk assessment in place in relation to a fire breaking out in the home and the level of support they will require. However, a fault has been identified with the internal fire doors. The fire doors are not closing sufficient to meet fire regulations due to the mechanical arm closure devices not being set at correct adjustment tension/levels. Whilst the tension could be easily corrected this would then cause further problems. For instance, if the doors are corrected, the force, weight and speed of the self-closing door could result in amputation or at least partial amputation should a service user or a member of staff be stood in line of the closing door. The manager and staff feel that this is a greater risk than that of service users and staff suffering smoke inhalation caused by fire. These issues have been passed on to senior managers within the local authority and the home is awaiting a decision as to what action will be taken to rectify these problems. A requirement has been made that consultation with the Fire Authority must take place as a matter of urgency. The kitchen is large and fitted with a range of modern appliances. The environmental health officer visited in August 2006, the majority of recommendations made have been addressed, with the exception of the fitting of fly screens to the windows. The manager explained that the fly screens have been ordered and will be fitted as soon as they arrive. Each service user has their own bedroom. Those service users who moved into the home from 56 The Crescent had input into how there room was decorated. Service users were able to choose their own colour scheme and the layout of the bedroom. Bedroom furniture was provided although some service users chose to bring their own furniture with them. Bedrooms were looked at during a tour of the home; each room was personalised with service users own memorabilia. All bedrooms have their own en-suite facilities. There is one main bathroom and two toilets, in addition to the ensuite facilities provided in bedrooms. The bathroom has been fitted with an assisted bath. The bath itself is a Jacuzzi. The staff explained that funding for overhead tracking has been applied for, and approved, as service users have to sit in the empty bath and then wait for it to fill. This is not an ideal situation. With the overhead equipment in place it will enable service users to be placed into the bath, which will already be filled with water. The home benefits from having outdoor space enabling service users to spend time in the garden. The manager explained that they are excited about the plans they have for developing the gardens further. The home recently won a competition run by Gardens Inc, a Kirklees project that involves people with learning disabilities. The prize money will go towards buying seeds etc in order to develop the gardens at Crescent Dale. The manager spoke of how their plans include a butterfly garden, an orchard and a sensory walk way. The residents will be involved with the project as much as possible and will benefit enormously once completed. The manager explained how those service users Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 20 with sensory impairments will benefit from the colours and the scent of the flowers. She went on to explain how they intend to dry the flowers out and use them as part of future handicraft activities. The home is clean and tidy. There we no traces of any unpleasant odours at any time during the inspection. Laundry facilities are excellent. Service users are able to take part in laundry duties accompanied by staff. Staff spoke about one service user in particular who enjoys being able to wash his own clothes. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 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 current staffing numbers and skill mix of staff are appropriate to the assessed needs of the people living at the home. Pre-employment checks are not being carried out in respect of all staff. Service users’ needs are met by appropriately trained staff. EVIDENCE: The rotas show that the home is well staffed. A typical shift consists of one coordinator and 3 care staff. There are two staff on duty during the night shift. The manager’s hours are supernumerary. Kitchen and domestic staff are employed at the home. The manager explained how there are a number of vacant hours at the home. A freeze on employment has meant the home is unable to recruit staff on a permanent basis at the present time. Vacant shifts are covered by casual staff and permanent staff working extra shifts. Six out of the 12 (50 ) care staff employed at the home have a NVQ level 2 qualification in Care. One member of staff has achieved NVQ level 3 in care. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 22 Staff records are held centrally. Two inspectors audited a sample of thirteen recruitment records on 28th September 2006. The sample covered thirteen Kirklees Metropolitan Council services and establishments. Records were generally of a good standard. However, three of the files did not have a CRB (Criminal Records Bureau) number recorded to evidence a check had been carried out. Two of those files did not have evidence that a CRB check had been carried out by Kirklees as the employer. Seven files did not include a recent photograph of the member of staff. The manager explained that all new staff are allocated a place on LDAF (Learning Disabilities Award Framework) accredited training as well as the local authorities induction training within the first 12 weeks of their employment. Training records were examined and there was evidence that the majority of staff have received the mandatory training they need to carry out their jobs effectively. Refresher training is provided on an ongoing basis. It was noted that only 2 staff have undertaken infection control training. As staff are required to deal with continence issues including stoma care, they must receive infection control training and a requirement will be made for this to take place within the next 5 months. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 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. 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. Service users benefit from a well run home. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The home is currently being managed by Ms Gill Pearce. In order to create a sense of stability and continuity, if Ms Pearce is to continue managing the home, an application to register her as manager, must be submitted to the Commission by the end of December 2006. Ms Pearce has over 18 years experience of working with people with learning disabilities. She has 5 years management experience and is part way through her Registered Managers Award. Ms Pearce explained that moving the service from 56 The Crescent at Dewsbury to the new accommodation has been Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 24 difficult but well worth it in terms of the facilities the new home has to offer for service users. The manager is responsible for completing a service improvement workbook, which is submitted to senior managers within KMC each year. The workbook is a quality assurance tool, which is used to plan for the year ahead in terms of setting objectives as well as evaluating the previous year. The staff are expected to look at what’s gone well and not so well and plan how to improve the service over the forthcoming 12 months. The manager explained how she is in the process of setting up service user meetings in order to seek the views of those people who live at Crescent Dale. The staff plan to use graphics in order to capture what takes place within the meeting so service users have a better understanding, as most would not be able to read minutes of the meeting. The meetings will be informal with only a few agenda items to discuss so as not to over complicate things. The manager said she tries to involve relatives and friends in giving feedback about how the home is managed. She recently sent letters out to each relative informing them that the home was expecting their first inspection by the Commission and would they like to make any comments about the service. She explained that the feedback she received was positive. In accordance with Regulation 26 of the Care Homes Regulations 2001 it is an expectation that representatives involved with this service, that is Kirklees Metropolitan Council, carry out monthly visits to the home. The purpose of the visit is to speak to service users and staff in order to form an opinion of the standard of care provided in the home. A tour of the home and examination of documents must also be undertaken. Following the visit a report on the findings must be produced, a copy of which must be made available for the purpose of inspection. There were no reports available for examination during this inspection, therefore no evidence that these visits are in fact taking place. The manager and staff make sure that so far as is reasonably practicable, the health, safety and welfare of people living at the home and staff is promoted, by way of appropriate written risk assessments and action to minimize risks. Despite the home following a “Stay Put” policy, fire drills must take place, as to date there has been no fire drills carried out. All staff must receive a fire drill at least twice a year. Weekly fire alarm tests take place. All staff received fire training on 11th April 2006 as part of their induction of the new building. The manager explained that she is due to attend a fire training event in the near future with a view to then cascading information to staff at the home. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 25 Risk assessments were seen in respect of safe working practices within the home. Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 2 X 2 X Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 27 N/a 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 YA24 Regulation 23 Requirement Consultation with the Fire Authority must take place as a matter of urgency in order to address the identified problem with the internal fire doors. Required pre-employment checks must be carried out on all staff. Recruitment records must include a CRB check carried out by the current employer and a recent photograph. All staff must receive infection control training within the next five months. An application to register Ms Pearce as manager of Crescent Dale, must be submitted to the CSCI. Management visits to the home must take place every month. A report on the findings must be produced and made available for the purpose of inspection. All staff must take part in a fire drill at least twice a year. Timescale for action 30/11/06 2 YA34 19 Schedule 2 30/12/06 3 4 YA35 YA37 18 8 30/03/07 30/12/06 5 YA39 26 30/11/06 6 YA42 23 30/11/06 Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 28 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 YA14 Good Practice Recommendations The manager should ensure service users are able to participate in short breaks/holidays of their choice, by other means, if staff employed by the local authority, are unable to do so. All staff should receive refresher training in respect of safeguarding adults. 2 YA23 Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Crescent Dale DS0000067158.V310597.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!