Inspection on 27/06/07 for Crescent Dale

This inspection was carried out on 27th June 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Crescent Dale 17/10/06

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 27th June 2007 09:20 Crescent Dale DS0000067158.V337363.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.V337363.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.V337363.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 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.V337363.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2006 Brief Description of the Service: Crescent Dale is owned and managed by Kirklees Metropolitan Council and provides a service to people 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.V337363.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out to the home by an inspector on the 27th June 2007. The visit commenced at 09.10am and the inspector left the home at 5pm. During this visit the inspector spoke to some of the staff and the home’s manager. Although the inspector engaged in conversation with some people living at the home they were not able to fully express the views about their life at Crescent Dale. However, it was clear through direct observation that people are well cared for in terms of their appearance and the interaction between staff and people who live at the home was relaxed and friendly. The inspector read care records, reviewed staff recruitment and training records and carried out a brief tour of the home. Alongside this, the staff at the home also provided information that was requested by CSCI (Commission for Social Care Inspection) about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. Prior to this visit surveys were sent out to obtain the views of people who live at the home, their relatives and people’s doctors. Eight surveys were sent out to people living at the home. Two of these were returned and those people had been supported by their advocate and/or link worker to complete the survey. Six surveys were sent out to relatives and three to advocates - one of these was returned. Two surveys were sent to people’s doctors - neither were returned. A friend of a person living at the home rang and spoke to the inspector prior to the visit to give feedback about the service; their comments are featured in the main body of this report. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: People are properly assessed before being offered a place at the home. They are able to visit the home on a number of occasions before they decide to move in. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 6 Relatives said they received enough information about the home to help make a decision as to whether or not Crescent Dale was the right place for their relative/friend. Crescent Dale provides a homely and friendly place for people to live. Everyone has a care plan so that staff know what support people need to help them. Care plans show how help is to be given in private and how people are to be respected. Care plans show each person’s preferred choices as to how they are supported. What has improved since the last inspection? What they could do better: People can make choices about their care but this is not always written down. This means staff may not always know what people really want or need. One relative said that there needs to be “more time outside Crescent Dale and more variety to life as there is too much routine.” Evidence seen during the inspection indicated that there are, particularly on weekends and evenings, insufficient staff to meet people’s individual social and recreational needs. People must be given the opportunity to pursue their own interests and hobbies and participate in leisure activities as they choose. Staff must be appropriately deployed to enable people to do this. Kirklees should listen to what people are saying about this and try to make things better. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Crescent Dale DS0000067158.V337363.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.V337363.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 and 4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People needs are properly assessed prior to moving into the home and are able to visit a number of times before they actually decide to move in. EVIDENCE: There was good evidence that any new person who is referred to this service by the learning disabilities team at Dewsbury is thoroughly assessed prior to being offered a place at the home. The manager explained how people are able to visit the home prior to them moving in. The amount of times people visit varies and depends entirely on the individual. There was good evidence in peoples’ care records that they had visited for tea on a number of occasions until they felt happy about staying overnight. The relatives’ survey returned to the CSCI indicated that the person had received enough information about the home to help them reach the decision as to whether or not Crescent Dale was right for their relative. Crescent Dale DS0000067158.V337363.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 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are generally of a good standard but not always up to date. People are able to make their own decisions about their own lives but this information is not being recorded. EVIDENCE: Evidence gathered from the relatives’ survey and from speaking to the friend of a person living at the home indicates that they are generally satisfied that the home meets the needs of people living there. One relative wrote, “Needs more time outside Crescent Dale”. Two care plans were looked at in detail and were generally found to be of a satisfactory standard. The original plan is detailed and provides good information about the level of care and support each individual requires. However, when reading other associated documents such as daily reports, doctors notes and reviews, the information detailed in the care plan is not as up to date as it should be. Although staff have been reviewing peoples’ care Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 11 needs they have not necessarily been amending the care plan to truly reflect changes. For example one person’s plan detailed that they go out regularly to see their relative. The inspector was told this contact ended some time ago. The same person was experiencing mobility problems but this had not been written into the care plan. Another’s person’s care documents included details of them gaining weight and that their dietary intake should be observed. There was nothing in the care plan to inform staff about the need to monitor weight. To enable staff to meet peoples’ needs the care plan must be kept up to date and relevant at all times. A recommendation has been made for this to be addressed. The manager explained that people living at the home are encouraged to make their own decisions about how they spend their time. The majority of staff have worked with the people living at Crescent Dale for a number of years and communicate well with them and have a good knowledge of what they like to do. Some people who do not have any close family receive support from external advocates. Although the manager gave assurances that people make their own decisions about how they spend their time, the daily reports provide very little evidence of this. It was difficult to get a picture of what people do on a daily basis. Some people spend time out of the home attending day centres or as part of one to one time with staff, but there is very little written about this. Likewise, a number of people prefer to stay at home for one reason or another but there was little if nothing written to show what they do. This needs to be addressed and a recommendation has been made to ensure staff provide written evidence of how they support people in making their own decisions and how they choose to live their lives. Surveys sent to people living at the home asked if they make decisions about what they do each day. One person said “never”. Another person said that they decide when to get up by knocking on the bed and that they like to tidy their bedroom before breakfast. This person also indicated that they make choices about what food they eat. Those surveys returned indicated that people are able to do what they want at different times of the day and night. Relatives surveys asked if they felt the care home helps their friend or relative to keep in touch with them. The returned survey said the home ‘always’ does. The person who contacted the CSCI said that the staff are very good at keeping in touch with them and sort out arrangements for their friend to come and visit, when she is well enough. Care plans include comprehensive risk assessments. These had been reviewed regularly and clearly outline the level of risk and measures in place to minimise the risk and associated hazards, for example people at risk of falling. Crescent Dale DS0000067158.V337363.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 People who use this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are not taking part or engaging in community based activities because of the shortages in staff. The quality of meals at the home is currently being addressed to ensure a healthier and varied diet is provided. EVIDENCE: The manager explained that none of the people living at the home take part in any full or part time employment. Four of the eight people living at Crescent Dale attend day centres such as Mencap, Ravensthorpe Resource Centre and Branches. The manager spoke of how the dynamics between the groups of people living at the home are good and everyone generally gets on well with each other. People are encouraged to access community facilities but only when there is enough staff on duty. Not having enough staff on duty appears to be commonplace. The inspector was advised that there are a number of vacant Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 13 posts at Crescent Dale, which is having a big impact on people not being able to participate in activities outside of the home. Throughout this visit staff often referred to not being able to do things with people because of staff shortages. Relative surveys asked how could the care home improve. One person wrote, “more variety of life, too much routine.” Most of those who attend day centres are often occupied during the week. However, there are a number of people, at least four, who don’t attend any of the day centres, by their own choice, they spend the majority of time at home. It was difficult to establish what people do as there was very little written evidence in place. At weekends when everyone is at home the staff explained that there is very little opportunity to take people out because of staff shortages so most people stay at home. The manager explained that each person is allocated one-to-one time with their link worker and this takes place one day a week. The amount of time the link worker spends with that person depends of the staffing levels at that time as well as other commitments for that particular day. The manager explained that she tries to ensure that staff make every effort to do something meaningful with that person on ‘their’ day but is aware that this can fall down when she is not there to make sure it happens. There is good evidence in peoples’ care records of what they like to do but this is not happening as often as it should. One off trips have been arranged and the manager said that some people had recently been to Blackpool for the day and two people had attended a ‘Body Shop’ party in Heckmondwike. On a positive note one person spends time in the home’s greenhouse, which they are said to thoroughly enjoy. This person is entering a ‘salad on a plate’ competition within the next month. Family and friends are welcome at the home at any reasonable time. The manager explained that home does not get many visitors, and a number of people do not have contact with their family. The rapport between staff and people at the home is very good; a lot of the staff have supported these people for a number of years. People are encouraged to take part in the daily running of the home including helping out with washing up, tidying bedrooms and attending to their own laundry. The atmosphere at Crescent Dale is very relaxed and friendly. Staff were seen supporting people in a caring and courteous manner. People were observed spending time in various parts of the home whether it be in their own rooms or in the communal areas available. The manager spoke of recent concerns she had with the meals being offered to people. She explained how they lacked in terms of variety and healthy Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 14 options. This was also picked up by the organisations representative who is responsible for carrying out quality visits to the home. New menus are currently being implemented taking into consideration peoples’ likes and dislikes as well as forming a menu with the ‘5 a day’ principles in mind. Pictures of food on offer will be used on the display board to help people choose what they want. A food-monitoring chart has been devised to monitor peoples’ intake, which will also be used as a quality audit in terms of establishing whether or not people enjoyed the meal. Specialist diets, such as diabetic, high calorie, low fat and soft diets are catered for. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ health care needs are generally being met and they receive support with medication and personal support in the way they prefer and require. EVIDENCE: People are supported in a way they prefer and require and care plans examined include detailed information about how people wish to be supported. There was good evidence in place to confirm that people have access to health care services. The manager explained that people are encouraged to visit their doctor’s surgery for appointments unless they are too ill to do so. One person’s care records indicated that they had lost a considerable amount of weight in a two-month period. There was no written explanation as to why this may have occurred. It later transpired that the person had been in hospital for a period of time, which could have contributed to the weight loss. Issues such as these must be recorded, giving details of any action to be taken. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 16 Appropriate policies and procedures are in place in respect of dealing with medication. The home operates a monitored dosage system supplied by the local chemist. Only authorised staff are able to administer medication to people to ensure it is done in accordance with the home’s policies and procedures. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. 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 and staff are trained on how to protect from abuse, neglect and self-harm. EVIDENCE: One person who completed a survey said they didn’t know how to make a complaint but they did know who to talk to if they were unhappy about something. A second person did know how to make a complaint and said they would tell their key worker if they were not happy. Kirklees Metropolitan Council has its own complaints policy and procedure that is used at Crescent Dale. 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. People are also informed of the procedure with the home’s statement of purpose and service user guide. There have been no complaints about this service since the last inspection in October 2006. The completed relatives survey indicated that they knew how to make a complaint and any concerns they had raised with the home had been dealt with appropriately. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 18 Concerns were recently raised about staff’s knowledge on how to deal with allegations of abuse including who to report it to. These concerns were raised following two allegations made in April and June of this year. Although all staff had already received adult protection training it was thought that staff would benefit from refresher training, this then took place in June 07. The majority of staff who attended the session are co-ordinator staff who normally have the lead role in reporting allegations of abuse. The manager explained that the training sessions was well received and staff appeared much clearer on what incidents needed reporting as an adult protection matter including who must be notified. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a homely, and comfortable environment that is clean and hygienic. EVIDENCE: Surveys completed by people living at the home said the home is “always” fresh and clean. One person said, “my bathroom smells nice”. Crescent Dale is a relatively new building and the standard of décor remains of a high standard. A tour of the home was undertaken which included looking at a couple of peoples’ own rooms. Their rooms had been personalised by the occupant and were clean and tidy. People were seen sitting in various parts of the home one person said he was enjoying a quiet moment on his own in one of the lounge areas. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 20 The home has a large garden area and since the last inspection the sensory garden has taken off beautifully. This part of the garden is very attractive and the scent from the different flowers is very pleasant. The home now has its own greenhouse and as mentioned earlier in this report one particular person spends time in there preparing cuttings and growing their own vegetables. As mentioned in the last report the bath is not appropriate for everyone and to date there has been no progress in replacing it. The manager explained there is only one person who is able to use the bath and the rest of the people living at the home have to get a shower instead. Whilst a number of people prefer a shower there are those who would like to get a bath. A recommendation is made to prompt the organisation to resolve this so that everyone at the home has a choice of either a bath or a shower. Crescent Dale DS0000067158.V337363.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 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Whilst people are cared for and supported by trained staff who have been selected and recruited as suitable to work with vulnerable people, there are at times insufficient staff on duty to fulfil individuals’ social care needs. EVIDENCE: Please also see pages 13 & 14 of this report in relation to lifestyle. Staff spoken to in relation to managing people’s social care needs felt that they had little sense of direction and that it was a juggling act trying to fit these in. The manager explained that all new staff are allocated a place on LDAF (Learning Disabilities Award Framework) accredited training as well as the local authority’s induction training within the first 12 weeks of their employment. Two new staff are currently awaiting this training. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 22 Since the last inspection and in accordance with the requirement made, the majority of staff have now received infection control training. Those who have not yet completed it have been given a date to attend. Five out of eight staff (62 ) have achieved a NVQ level 2 or above qualification in care. The employment records for two staff working were looked at. Both records held the required information to ensure that people are protected by the home’s recruitment practices. Surveys asked if people felt the staff treat them well. One person said “always” and one said “usually”. Crescent Dale DS0000067158.V337363.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, 38, 39 and 42 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ social lives are being compromised by the lack of management direction and reduced staffing levels, although in terms of health and safety people are being protected. EVIDENCE: Since the last inspection in October 2006 the management structure at Crescent Dale has been reduced in that the manager, Gill Pearce, is now responsible for both Crescent Dale and Mill Dale (the sister home on the same site) and shares her time between the two. At the last inspection there were three permanent co-ordinator staff in post. At this inspection there was one permanent co-ordinator and one person acting up into the position. According to staff this has had a great impact on the overall running of the home and as Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 24 a result arranging staff to take people out on an evening and weekend is not happening as often as is should be. Whilst examining the duty rotas referring to June 2007, nineteen co-ordinator shifts needed to be covered. Only three were. This meant that the home was left without senior level cover on sixteen occasions – with only co-ordinator support from Mill Dale. When cover cannot be provided the co-ordinator from Mill Dale is asked to oversee Crescent Dale. Whilst this may be satisfactory to cover emergency situations, over the long term this is adversely affecting outcomes for people living at the home due to the lack of management input into the day- to- day needs of people. There has been very little development in introducing a quality assurance system that invites people associated with the home to seek their views. The manager spoke about a number of ideas she has that involves speaking to people on an individual basis to obtain their views. To date this has not yet happened and a requirement is made to ensure it takes place by the end of September 2007. The manager must see this as an area of development, as the people living at the home have not been actively involved in any quality monitoring since the home was registered in April 2006. Involving people in this way helps to ensure that the home is run in the best interests of those who live there. 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. Fire records were examined during the visit and there was good evidence that weekly fire tests are carried out and a fire drill took place on 20 May 2007. Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 1 2 X X 3 X Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA14 YA38 Regulation 16 Requirement People must be given the opportunity to pursue their own interests and hobbies and participate in leisure activities as they choose. Staff must be appropriately deployed to enable people to do this and those staff at a more senior level (coordinators) need to delegate these tasks to ensure they take place. An application to register Ms Pearce as manager of Crescent Dale, must be submitted to the CSCI. Timescale of 30.12.06 not met. In order to ensure that the home is run in the best interests of the people who live there the manager must implement an effective quality monitoring system that actively seeks the views of people associated with the home. Timescale for action 30/08/07 2 YA37 8 30/08/07 3 YA39 24 30/09/07 Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 27 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 2 3 4 Refer to Standard YA6 YA7 YA16 YA19 Good Practice Recommendations Peoples’ care plans should reflect their current needs to ensure staff provide the right level of care and support to them. Daily reports and care plans should reflect how people choose to live their lives in order to demonstrate that they are able to make their own decisions. The organisation should take on board views made by relatives about there being “too much routine” and “not enough variety”. Identified health care needs such as significant weight loss should be acted upon and the appropriate advice should be sought, such as monitoring dietary intake or referral to a health care professional. Records of any action taken should be maintained. Every effort should be made to ensure that people are able to access bathroom facilities that meet their personal preference and requirements. 5 YA27 Crescent Dale DS0000067158.V337363.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square 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.V337363.R01.S.doc Version 5.2 Page 29 - 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!