Inspection on 22/09/05 for Crescent House

This inspection was carried out on 22nd September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Crescent House 19/05/08

Crescent House 26/07/07

Crescent House 10/05/06

Crescent House 12/04/05

Crescent House 28/10/04

Crescent House 27/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Crescent House 108 The Drive Hove East Sussex BN3 6GP Lead Inspector Jane Jewell Unannounced Inspection 22 September 2005 10.00 X10015.doc Version 1.40 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 House DS0000014193.V249574.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 House DS0000014193.V249574.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Crescent House Address 108 The Drive Hove East Sussex BN3 6GP 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) 01273 732291 The London & Brighton Convalescent Home Mrs Jennifer Susan Downes Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to accommodated is 17 Service users should be aged 65 years or over on admission That the home may accommodate one named service user who has mental health needs 12th April 2005 Date of last inspection Brief Description of the Service: The home has been owned for over a hundred years by the London and Brighton convalescent Home, a charity. The home is a detached Edwardian property located half a mile from Hove. Main line train services are within walking distance and the home is near to bus routes into Hove and Brighton. The home is registered to provide care for up to seventeen older people. The home is on three levels, ground, first and second floor, with a chair lift providing access to to first floor. Service users accommodation is situated on the ground and first floor with the second floor used as a storage area. All bedrooms are for sinlge occupancy with six having ensuite facilities. There is a shared dinning room, lounge and conservatory. The home has a well-maintained rear garden with the front garden gravelled to provide off road parking. The homes literature states that its mission is to assist its residents in maintaining a highest quality of life, as well as quality of care. And assures its residents individual care with respect to their privacy, dignity safety and security. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken between 9.50am to 2.20pm. Since the previous inspection a monitoring visit has been undertaken to assess the progress made towards meeting the shortfalls in practices noted at previous inspections. The inspection was undertake with Mrs T Mcneil (Head of care) Mrs J Downs (Manager) and Mrs K Warn (Deputy). There were thirteen residents living at the home. The inspection involved a tour of the premises and examination of the homes records. Eight staff, nine residents and four visitors were consulted. The focus of the inspection was to look at the experiences of life at the home for the people living there. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? Much progress has been made towards addressing the shortfalls in practices previously noted. This has improved resident’s safety, infection control measures and staff training. Continuing investment in the homes environment is creating a comfortable and pleasant environment in which to live. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 6 Staffing levels have increased which has enabled more individual time to be spend with residents. What they could do better: Staff must be more closely supervised to ensure continuity of practices. Care plans need to provide clearer guidance on the needs of residents. This is to provide guidance to staff on the support needed to each resident. Although the level of activities has improved further work is still needed to ensure that residents are provided with the opportunity to undertake suitable occupation and stimulation. The system for residents to be able to call for assistance needs to be reviewed to ensure that it is easily accessible in all bedrooms. The management of risks faced by some window restricted being dislodged and cleaning chemicals not being stored securely must be eliminated immediately. In response to the draft inspection report, the provided returned to the CSCI an action plan of how they intend to meet the requirements and recommendations made from this inspection. 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. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 4 There is a good range of information about the home and the services it offers which helps prospective residents and their representatives decide whether the home would be suitable. The way in which prospective residents are assessed ensures that the home admits only those residents who’s needs can be met by living at the home. EVIDENCE: There is a significant amount of information about the services offered at the home. As well as a comprehensive statement of purpose and service user guide there is a useful booklet on the most frequently asked questions about the home. These are all displayed around the home including previous Inspection reports. A resident’s family said that they were provided with all of the information they needed to help them decided whether the home would be suitable. Following a previous recommendation staff have now been instructed to become familiar with these documents, in particular the aims and objectives of the home. This is important for the home to be able to achieve its stated purpose. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 9 Documents seen for recent admissions showed that residents are only accommodated following a comprehensive assessment of their needs by a member of the management team. Those undertaking recent assessments had a good knowledge of the homes admission criteria and interpreting health care assessments. The assessment involved visiting the prospective residents, either at hospital or current address, to gather information about their needs. Where appropriate, information about a prospective residents needs had also been gained from other sources including residents representatives and health care professionals. Where social services were the funding authority copies of their needs assessments were also obtained. The level of information obtained about prospective residents enabled the home to make an informed decision whether the home could meet their needs. The information obtained during the assessment process them forms the basis of a residents care plan. This helped ensure that staff were aware of the assessed needs of the new residents. Residents looked relaxed and comfortable in their surroundings and describe their experience at the home as: “I like living here” “Love it” “Made to feel so welcome” “Quite content really” and “Can sometimes be a little boring”. A number of residents have developed specialised needs since living at the home. To ensure that these needs are properly identified and addressed, it remains necessary for staff to undergo training in the care of people who have Alzheimer’s and dementia. Where needs have increased to an extent that the home is no longer able to care for a resident, prompt action has been undertaken to support them to move to a nursing placement. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Although each resident has a comprehensive plan of care, staff were not always aware of what was recorded in them and the assessed needs of residents. Residents health needs are well met with evidence of regular input from health care professionals. The medication systems were well managed promoting good health. EVIDENCE: Five individual plans of care were sampled. Comprehensive information is gathered about each resident and compiled into several documents. These include risk and needs assessments, basic information, daily notes and a plan of care. Due to the bulk of information obtained and the difficulty this can present for staff in retrieving essential information it has been previously suggested that a brief summary of daily and nighttime needs be recorded. It was reported that this is gradually being developed. It is now required that care plans provide clear guidance for staff on the assessed needs of residents. Care plans are predominantly developed and reviewed by the head of care with the daily notes completed by care staff. Staff were not always aware of the contents of care plans and therefore the assessed needs of residents. In order to increase staff awareness it has been recommended that staff are more Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 11 actively involved in the development and review of care plans. In line with previous requirements the head of care reported that residents are involved in writing and updating their care plans. A daily record for each resident is maintained, the standard of which was variable. So that a clear account of actions and events, in a residents life, is consistently maintained it is recommended that quality audits be undertaken on the standards of record keeping by care staff. In accordance with previous requirements risk assessments now include the actions needed to manage identified risks. Records of medical intervention showed that the home works closely with health care professionals including GP’s, District and specialist nurses, chiropodists, opticians and dentists. This is to ensure that residents receive the necessary health care intervention. Residents consulted said that when they have asked to see a Doctor then this has been sought promptly. Where medical treatment has been undertaken at the home then this has been carried out in private. Several male carers work at the home and residents consulted continue to state that they did not have any preference in the gender of staff undertaking personal care. Clear records were maintained of all medicine movement including when received, administered or disposed off. Good practices were noted on the individual instructions provided for staff on the administration of “As required” medication. These made clear the individual requirements for when these medicines should be administered. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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, 14 and 15 Opportunities for occupation and stimulation still need to be improved to provide a more interesting lifestyle for some residents. Flexible routines continue to be part of daily practice at the home. Links with families are valued and supported by the home. The majority of residents spoke positively about the meals provided. EVIDENCE: To increase opportunities for occupation and stimulation it was previously required that an activities plan be developed and implemented. Although this had been developed staff were not always implementing it. Therefore it was not clear what opportunities for leisure or occupation had occurred. Residents said they play bingo, watch TV, videos and do some knitting. However five residents continue to state that they are often bored. Staffing levels have increased during the afternoon, which enables staff to spend time with residents talking or undertaking activities. Several residents had made a choice to remain in their rooms and not participate in any organised events, which was respected by staff. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals. Visitors said that they were kept informed of any changes to their relatives needs and felt able to approach any member of staff with any concerns or queries they had. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 13 Residents said that their visitors were able to visit them at any reasonable time. One resident said how important having their own telephone was in order to be able to keep in contact with their family and friends. Three relatives who visited the home on behalf of their relative to see if the home would be suitable said that they chose the home because it had such a friendly and relaxed atmosphere. Residents said that they could get up and go to bed when they wanted. Several residents commented upon how flexible staff were, for example on the frequency and timing of bathing. A choice of main meal is provided with records indicating that most residents have the main menu option. Specialist diets are appropriately catered for including diabetic, low cholesterol and vegetarian. The meal served on the day of the inspection looked appetising and plentiful with individual preferences being catered for. For example large/small meal, additional vegetables. Variable feedback was received regarding the quality of meals with the majority of residents speaking positively about the food. Residents comments included: “Alright” “Very good no complaints” “ The food is excellent” “its very nice” “Traditional cooking” “I prefer it when the cook prepares the meals” “Can vary depending upon who’s cooking”. These comments were feedback to the weekday cook who was not aware of any dissatisfaction with food quality. They agreed to monitor the situation. Residents stated that in addition to the main meals regular snacks and hot drinks were offered and all said that they felt able to ask at any time for additional drinks or snacks. The majority of residents eat their main meal in an attractively decorated dinning room, while others prefer to eat in their bedrooms. The kitchen has recently been refurbished to provide a more suitable environment in which to cook. This has been done to a good standard with the floor covering due to be replaced in the near future. The kitchen was clean and well organised. Records required to be kept for food safety reasons were being completed. In line with previous requirements entry to the kitchen has been restricted for health and safety reasons. All persons entering the kitchen are now provided with appropriate protective clothing in line with infection control guidelines. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 There is satisfactory complaints system in place with residents and their representatives saying that their views are listened to and acted upon. There are procedures and practices in place that supports the protection of vulnerable adults. EVIDENCE: There is an accessible complaints procedure for residents, they’re representative and staff to follow should they be unhappy with any aspect of the service. No complaints have been recorded since the last inspection. All residents and their representatives consulted said that they felt confident to approach members of the management team with any complaints or concerns. Where they have had to do this then they have received a prompt response. There are clear procedures in place for staff to follow to reported suspected abuse. Staff have also received formal training in adult protection and prevention of abuse and showed some understanding of their roles and responsibilities under adult protection. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21,22, 23 and 26 The continuing investment in the homes décor has significantly improved the environment making it a comfortable place to live. The home was found to be clean and free from offensive odours. The residents call system still needs to be reviewed in order that residents can easily call for assistance when needed. EVIDENCE: The home is near completion of a refurbishment programme, which has seen major investment into the homes environment. This has involved the redecoration of all but a few bedrooms, toilets, corridors, some communal spaces and the exterior of the home. This has been completed to a good standard and creates a homely and comfortable environment in which to live. Although some works remain outstanding plans are in place to address these in the near future. This includes the re-carpeting of the conservatory and refurbishment of the first floor toilets/bathing facilities. The time taken for funds to be released by the homes governing charitable body has significantly improved. This has resulted in maintenance and redecoration works being addressed more promptly. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 16 Communal space consists of a dinning room, lounge and conservatory on the ground floor. These are decorated to a good standard with furnishings that are domestic in character. The conservatory overlooks a well-maintained rear garden. Several residents said they enjoyed watching the wild life from the comfort of the conservatory and sitting in the garden in nice weather. There are adequate number of toilets located around the home including six bedrooms, which have ensuite facilities, and one also has a shower. There are two assisted bathrooms on the ground floor. There is a standard bath on the first floor, which is not used, as it is too low for residents to use safely. Plans are in place to upgrade these and create additional ensuite facilities. The manager is aware of the need to ensure that there is adequate number of communal bathing facilities available on the first floor. There is a need to repair and reseal a tiling panel around the ground floor bath to limit the risk of cross infection. Eleven bedrooms are below the recommended 10sq meters. Several occupants of these rooms were consulted who felt that they had sufficient space for their needs. All bedrooms were personalised with domestic style furniture and fittings, together with suitable bedding and carpeting. There is a variety of aids and adaptations around the building to support residents independence. This includes grab rails, raised toilet seats, assisted baths and chair lift. A call system is fitted throughout the home, which in some cases is a doorbell type mechanism attached to a wall. In line with previous requirements extension cords have been provided in some bedrooms to enable it to be reached from a bed or chair. However not all call bells were easily accessible in bedrooms including one which had been obstructed. The manager has been required to address this a matter of priority to ensure that residents can call for assistance when they need. As this has been a recurrent concern there is now a need to assess the accessibility of all call points in the building. Residents felt that their clothes were suitable laundered and all residents clothing was observed to have been laundered to a good standard. All parts of the home inspected were clean and free from offensive odours. There were two cleaners on duty at the time of inspection. Residents confirmed that the home is kept clean and free from offensive odours. Shortfalls in infection control practices noted during previous inspections have been addressed. This includes the provision of hand washing facilities in the laundry, availability of protective clothing and the development of policies on the safe disposal of human waste. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 All residents consulted confirmed the sensitive care they receive from an established staff team who were observed by the inspector to operate in an appropriately caring and patient manner. There is sufficient staff on duty to ensure that residents receive the level of care they need. EVIDENCE: The staffing level noted at inspection was for two carers and a manager to be on duty until 2pm. In addition there was a cook and domestic staff. After 2pm there were three staff on duty until 8pm. In line with previous requirements the afternoon staffing level has increased. The arrangements for covering leave and sickness have improved ensuring that minimum staffing levels are now being consistently maintained. Night staffing levels are supported by a management “On call” rota. Records are now kept of any call outs and on night time tasks. This enables the manager to monitor the level of need at night to ensure adequate nighttime staffing levels be maintained. Residents described staff as: “Very Kind” “Helpful” “Alright” “Very good” and “I think some are wonderful”. All residents consulted said that there was sufficient staff on duty to get the help that they needed. Staff felt that they had sufficient time to spend individual time with residents. The core staff team have worked at the home for many years and have considerable experience in caring for older people. Staff demonstrated very positive attachment to residents and there was much good care practice in evidence. The core staff team work predominately morning shifts and there Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 18 was a clear division between morning and afternoon staff. There was a lack of understanding between the shifts and little team ethos, which was affecting the continuity of services provided to residents. It was recommended, at the time, that staffing deployment be reviewed. Subsequent to the inspection it was reported that this had been instigated and staff now work a mixture of shifts. No staff have been recruited since the last inspection and therefore this standard will be monitored at future inspections. The management team did demonstrate a good understanding of the recruitment practices needed to ensure residents safety. Staff training has benefited from better planning and resources. Staff undergo core training topics such as moving and handling, first aid, food hygiene and fire safety. Additional training in the care of older people including who have Alzheimer’s and dementia remains required. It was reported that this is due to be undertaken in the near future. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36, 37 and 38 Progress has been made in providing a clearer sense of leadership and direction. This has been achieved through clarifying the management functions at the home to staff and service users. There remains a need for greater supervision of staff to ensure continuity of standards. Some good practices were noted in relation to health and safety, however the safe storage of cleaning chemicals and the refitting of some window restrictors must be given a priority. EVIDENCE: Many of the management tasks are delegated amongst the management team, with the agreement of the inspector this is an effective way of managing the home at this particular time. The management team is made up of the, manager, deputy, head of care and medication co-ordinator. The manager is aware however that they have overall accountability for the home. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 20 The inspector has previously expressed concern regarding the lack of management presence during the afternoon period. This is because all members of the management team are rostered to finish by early afternoon. Despite previously assurances that management cover had been extended this was not being consistently applied. Following the inspection the management team met with the Responsible Individual to review the afternoon management cover. It has subsequently been confirmed that a management afternoon roster has been implemented. Although many procedures have been developed that would enable information to be gathered about the quality of services provided these were not being followed. It is required that an overall quality assurance system be develop to monitor practices at the home, which also obtains feedback on the quality of the services provided by residents and others involved in their care. It was previously required that persons working at the home are appropriately supervised. This relates to both informal, day-to-day overseeing of staff and formal, which should cover aspects of practice, philosophy of care, and career development needs. This was assessed as not yet having been fully implemented and remains essential to ensure there is continuity in staff practices. The head of care takes responsibility for the administration and record keeping at the home and generally these were well organised. However many of the homes own procedures relating to record keeping were not being followed. The standard of recording in some documentation was variable. This highlighted the need for greater supervision and monitoring of staff and standards at the home. Practices that were noted that promote the health and safety of resident’s, staff and visitors include: • Good practices continue to be noted in the management of falls, which includes a clear account of accidents and risk assessments review following each fall. • Regular servicing, training and testing of fire safety equipment. • Hot water mixer valves are fitted to outlets accessible to residents and all those checked delivered hot water within the required safe temperature range. Regular hot water checks are also undertaken by the home. • Radiators have been fitted with guards to prevent accidental scolding. Although window restrictors had been fitted to prevent the risk of falls and for security, some had been dislodged. It was immediately required that they be reattached. Not all cleaning chemicals were stored securely. This has been a recurrent concern at the home and immediate steps must be taken to illuminate this risk. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 2 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 1 2 2 Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES 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 OP7 Regulation 15(1) Requirement That care plans provide clear guidance for staff on all aspects of the health, personal and social care needs of service users and which make explicit the actions needed to meet these needs. That a programme of activities be developed and implemented based on the likes and dislikes of residents and which is made available to service users. (Made at inspection of 12/4/05 with timescales of immediate not met) That adequate communal bathing facilities are available on the first floor. (Made at inspection of 30/8/05 with timescales of immediate not met) That a call system with an accessible alarm facility is provided and accessible to all service users in their bedrooms. (First made at inspection of 28/10/04 with timescales of immediate not met) That all bathroom and toilet tiling is secure and provides an DS0000014193.V249574.R01.S.doc Timescale for action 30/11/05 2 OP12 16(2)(m) 30/11/05 3 OP21 23(2)(j) 30/01/06 4 OP22 23(2)(n) 30/11/05 5 OP26 13(3) 30/11/05 Crescent House Version 5.0 Page 23 6 OP30 18(1)(c) (i) 7 8 OP33 OP36 24(1) 18(2) 9 10 OP38 OP38 13(4)(a) 13(4)(a) impermeable surface for effective cleaning. That staff undergo training in the care of older people including Alzheimer’s and dementia. (First made at inspection of 28/10/04 with timescales of immediate not met) That a system is established and maintained for monitoring the quality of the care provided. That persons working at the home are appropriately supervised. (Made at inspection of 12/4/05 with timescales of immediate not met) That hazardous substances are securely stored within the home at all times. That windows that pose a risks from falls or security be fitted with restrictors. 30/11/05 30/11/05 22/09/05 22/09/05 22/09/05 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 Refer to Standard OP7 OP7 OP22 Good Practice Recommendations That all care staff are involved in the development and review of care plans. That regular quality audits be undertaken on care planning documents. That the accessibility of all call points in the building be assessed. Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Crescent House DS0000014193.V249574.R01.S.doc Version 5.0 Page 25 - 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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