Inspection on 08/07/08 for Cressage House

This inspection was carried out on 8th July 2008.

CSCI found this care home to be providing an Good service.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cressage House 20/02/08

Cressage House 20/06/07

Cressage House 21/06/06

Cressage House 06/10/05

Cressage House 14/04/05

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Dalewood Respite Care

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Cressage House 30 St Edward`s Road Southsea Hampshire PO5 3DJ Lead Inspector Mick Gough Key Unannounced Inspection 8th July 2008 09:30 Cressage House DS0000062441.V367390.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 Cressage House DS0000062441.V367390.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. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cressage House Address 30 St Edward`s Road Southsea Hampshire PO5 3DJ 023 9282 1486 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) Mrs Susan Ann Walker Mrs Ann Grace Care Home 13 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (13), Mental disorder, excluding of places learning disability or dementia (13), Mental Disorder, excluding learning disability or dementia - over 65 years of age (13) Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users in the category LD(E) and MD(E) only to be admitted with a dual diagnosis. Service users in the above categories not to be admitted under 40 years of age. 20th February 2008 Date of last inspection Brief Description of the Service: Cressage House is a small care home situated in a residential area of Southsea, Portsmouth. The home is registered for thirteen service users within the category of younger adults; however, the home also accommodates two service users within the older persons category as they have lived at the home for many years. The home is situated close to local amenities and a short distance from the town of Portsmouth. The home has a minibus and as such service users are able to access venues and activities outside of the home and local area. The home provides a range of accommodation in single and double bedrooms, with a high number of shared rooms currently. On the ground floor is a lounge, dining room and a smoker’s room. The home also has a domestic kitchen, accessible via a number of steps, and service users may access the kitchen to prepare snacks and drinks as they choose. The home has an enclosed rear enclosed garden that is accessible to service users. There is a large office to the front of the home on the ground floor. The current range of fees are £300 - £500 per week depending on the type and level of support required. An up to date scale of fees can be obtained by contacting the home. Residents are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This report details the evaluation of the quality of the service provided at Cressage House and takes into account the accumulated evidence of the activity at the home since the last key inspection of the service, which was carried out in February 2008. The inspection took into account; the previous key inspection report and information from what other people have told us about the service. Comment cards were sent out to residents at the previous inspection in February and 6 service user surveys, 3 relatives and 6 staff, returned them to us. Included in the inspection was an unannounced site visit to the home, which took place on the 8 July 2008. Evidence for this report was obtained from reading and inspecting records, looking around the home and from observing the interaction between staff and users of the service. It was also possible to speak with 7 people who live in the home, 2 members of staff and the home’s manager who assisted the inspector throughout the visit. The home is registered to provide support for 13 residents and at the time of the inspection there were 12 people living at the home. What the service does well: From talking with residents and from the comments received it was clear that residents were happy living at the home and that staff and residents got on well together. Comments received from residents included “I am very happy here”, “I have lived here for 4 years and am very happy”, “its very nice” and “I can come and go whenever I want and the staff help me out when I need them to” The home provides care and support to enable residents to live fulfilling and meaningful lives. Residents are given choice in their day-to-day lives with appropriate support provided by staff at the home. There is an effective care planning system in place and each resident has a key worker who assists individuals to be involved as much as possible in this process. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 6 Staff at the home treat residents with dignity and respect and residents have access to a full range of healthcare support. The home provides a homely and welcoming environment and residents told us that they were happy at the home. Meals in the home are good and offer a choice at meal times and there is a varied diet. Residents told us that the food was good. What has improved since the last inspection? What they could do better: There were 2 requirements made as a result of this visit and there was one requirement carried over from the last visit. Other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report. General observations were: It was a requirement at the last visit that the home’s statement of purpose (SOP) and service user guide (SUG) is updated, and the timescale for this to be completed has not yet expired, therefore this requirement will be carried forward into this report. Care plans were reviewed monthly, however the monthly recording could be improved to provide more evidence of care delivery. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 7 The home must ensure that any controlled drugs are stored in a controlled drugs cabinet that meets the legal requirements as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. The provider has started to carry out monthly regulation 26 visits to the home and must continue to carry out these visits to monitor the standards and outcomes for residents and provide a report, which must be kept at the home. We were not able to view an electrical wiring certificate for the home’s fixed wiring and this will need to be obtained to evidence that the electrical wiring in the home is safe. 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. Cressage House DS0000062441.V367390.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 Cressage House DS0000062441.V367390.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes statement of purpose and service user guide, requires updating but users of the service can be confident that there will be a detailed assessment of their individual needs before they move into the home. EVIDENCE: It was a requirement at the last visit that the homes statement of purpose (SOP) and service user guide (SUG) be updated, and the timescale for this to be completed has not yet expired, therefore this requirement will be carried forward into this report. We discussed this issue with the homes manager who told us that she was working on both the SOP and SUG and was looking at recording these onto audio cassette so that it would be more user friendly for residents. There have been no new service users admitted to the since the last inspection. The home had a clear admissions policy and the manager stated that she would carry out her own assessment and also obtain Social Service assessment before anyone moved into the home. Assessment forms in residents files showed that the assessment form used by the home covers: Self Care, washing and bathing, health issues, likes and dislikes, grooming, dressing and undressing, communication, household skills, social skills, domestic skills, budgetary skills, use of money, leisure activities and work and Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 10 education The assessment form is used for the basis of the residents care plan and those files seen for residents had a good assessment carried out before they moved into the home. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed needs and personal goals are set out in an their individual plan of care and they are involved as much as possible in the care planning process. Staff at the home respect resident’s rights to be involved and make decisions about their day-to-day lives and they are supported in this process by staff at the home. Residents are supported to take responsible risks as part of their independent lifestyle. EVIDENCE: The completed AQAA stated that care plans were person centred and that goals and ambitions are well documented We were able to confirm this when we looked at care plans for 2 residents and these were comprehensive documents and care plans seen reflected the aspirations and goals of residents were written clearly and could be followed easily. Plans gave staff clear information on what support was required and how and when this should be given, there was information on the residents mental and physical health, daily routines, daily living skills, personal care needs, social and leisure, budgeting skills, interactions with other residents and communication. There was also a Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 12 good personal profile of each residents and this gave good information on the residents past history, their goals and ambitions and also their views on how they wanted to be supported. Residents were involved in the care planning process as much as possible and care plans were person centred. Recording was noted on daily sheets and these gave information on what the resident had been doing throughout the day. Care plans were reviewed monthly, however the monthly recording could be improved to provide more evidence of care delivery, the inspector discussed recording with the home’s manager who said that they would address this issue. Residents were actively involved in the decision making process in the home, they were consulted on all aspects of their lives and their wishes were respected and acted upon. The home held regular residents meetings (once per month) and there were also one to one sessions with their key worker. All staff know each resident well and residents were able to express their views and wishes to staff who then ensure that their wishes are acted upon. It was very clear by observing the staff interacting with residents that they are able to make their own decisions. Those residents spoken with told us that they were able to make their own decisions and that staff respect their wishes and views. Each resident’s care plan seen had risk assessments in place for identified risks. Both of the care plans seen contained risk assessments and these gave details of the risk, the support required and the action to be taken to minimise the risk. Risk assessments were seen to be in place for: mental health, self harm, self neglect, verbal abuse, use of the kitchen, smoking in nondesignated areas of the home and for self medication. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 13 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident are supported to take part in age, peer and appropriate activities and they access the local community on a regular basis. Is this evidence Mick? The homes visiting policy supports residents to maintain family links and friendships both inside and outside the home and their rights are respected. Residents are offered a healthy and varied diet and enjoy their meals at the home. EVIDENCE: One resident at the home goes to a local college to develop his independent living skills and also to help develop his personal and employment skills. Another resident helps out a local café once per week and others attend local support groups. Currently no one at the home is in any form of paid employment but we were told by the manager that the home would support any resident to find employment if they wanted to. Most of the residents are able to access the community independently and we saw residents coming and going throughout the visit. One resident went out to visit a friend on the Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 14 morning of our visit but returned for lunch. All residents spoken with told us that they were free to come and go as they please and they are encouraged to be part of the local community and are supported to be aware of what events are happening locally, they regularly go shopping, visit local pubs and cafes and attend community events in the local area. One resident told us “I can come and go as I please” Resident’s are supported to maintain and expand their social networks. Families are able to visit freely and some resident go to visit their families and friends. Residents are able to invite their friends to their house for visits and for meals, and we observed staff supporting one resident to call her friend on the homes phone. Daily routines in the home promote independence as much as possible and residents are involved in all aspects of the day-to-day running of the home and staff were observed knocking on residents’ doors before entering and seeking permission for them to enter their rooms. Staff were observed interacting with residents and their preferred form of address was used. All of the residents spoken to said that they were happy at the home and liked being involved in decision making. Mail is given to residents unopened and staff support them with their mail if requested. Residents are able to access all areas of the home and there was a regular stream of residents who came into the office during the visit to talk to the manager. Residents were able to choose if they wish to be alone in their rooms or be in the company of other residents and staff. Residents are involved in the planning of meals and staff provide support to ensure they have a balanced diet, residents take it in turns to choose meals and one resident told us that the choice of meals on the day of the visit was hers with the lunch time meal being chilli con carne and rice followed by angel delight. We observed staff cooking sausages for 2 residents who did not want the main choice. Food shopping normally takes place twice a week with top up shopping being done on a day-to-day basis. Residents told us that they liked the food at the home and they were able to make their own drinks and snacks whenever they wanted. Cressage House DS0000062441.V367390.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 & 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 service users physical, emotional and health needs are met. The home’s policies and procedures with regard to medication provide protection for service users, however the storage of controlled drugs needs to be improved. EVIDENCE: Care plans for individual residents gave information on personal care needs and this is normally only verbal prompts, however two residents need more support and care plans give details of the support required such as running a bath and helping residents to wash their hair. There was information on individual’s personal care skills so that staff could offer the correct type of support. Residents spoken to said that staff were always around to help if they needed it but told us that they can do things for themselves. Residents’ personal profiles gave good information on resident’s abilities and highlighted areas where support was needed. Residents are registered with two different GP surgeries, but have a number of different GP’s. Some residents have their own dentist while others can be checked over through the local health centre. Eye tests are conducted by a Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 16 visiting optician service and the local mental health team and also the learning disability team provide additional support if required. District nurses visit when required and any other health care professionals are arranged through GP referral. Staff at the home monitor residents health and support them to access appropriate healthcare professionals and to attend any appointments. The home has clear policies and procedures in place for the receipt, storage and administration of medication. The home uses a monitored dose system from a local pharmacist and staff at the home have undertaken training in medication administration procedures. Currently one member of staff at the home administers her own medication and there is a risk assessment in place. The home’s medication administration records (MAR) was looked at and these was found to be up to date and correct with no gaps. Currently the home keeps some controlled drugs (temazepam) and these are stored in a locked box inside the medication cupboard, which is also locked, however the storage does not meet the requirements for the storage of controlled drugs as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. The law concerning the storage of controlled drugs has recently changed and the home must ensure that any controlled drugs must be stored in a proper Controlled Drugs Cupboard. In brief, the requirements for CD storage are: • Metal cupboard of specified gauge • Specified double locking mechanism • Fixed to a solid wall or a wall that has a steel plate mounted behind it • Fixed with either Rawl or Rag bolts Suppliers of CD cabinets can confirm that a cupboard meets the legal requirements. Cressage House DS0000062441.V367390.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a simple, clear and accessible complaints procedure and the home’s policies and procedures help to protect residents from any form of abuse. EVIDENCE: The home has a clear complaints procedure and this includes timescales for the complaint to be addressed and gives details of how to contact the CSCI. The home keeps clear records of any complaints made and also records responses. The home’s completed AQAA told us that there had been two complaints made since the last visit to the service and the home’s records of complaints confirmed this. The complaints that had been made were disagreements between residents, but the home had taken concerns seriously and had investigated the concerns. Records showed that actions had been taken within the required timescales and both complaints were resolved to the satisfaction of all concerned. Residents spoken with were aware that there was a complaints procedure and said that they would speak to a member of staff if they were unhappy. Staff members were aware of the homes complaints procedure and said that they would support any resident to make a complaint. The AQAA told us that there had been no adult protection issues at the home and the manager confirmed this. The home has a copy of the Hampshire adult protection procedure and all staff have received training in the protection of vulnerable adults and there were two members of staff who were waiting to complete refresher training. Staff spoken with told us that they would talk to the manager if they had any concerns and were aware that social services Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 18 would take the lead in any adult protection issues. that they felt safe at the home. Residents we spoke to said Cressage House DS0000062441.V367390.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a well-maintained environment and residents have access to comfortable indoor and outdoor facilities and the home was clean, pleasant and hygienic and free from offensive odours and this provided a pleasant environment for residents and staff. EVIDENCE: A tour of the home was conducted and the home is laid out over 3 stories, with stair lifts available to access the upper floors. There were 6 single rooms one of which was en-suite and there were also 3 double rooms. We spoke to residents who told us that they were happy with their rooms, as were those residents that shared a room, although one resident told us that he would like more space. There was sufficient numbers of bathing and toilet facilities close to residents’ bedrooms and all toilets had suitable hand washing facilities. All areas of the home were clean and furniture and fittings were of reasonable quality and homely in appearance and there were no offensive odours. There was a separate laundry, which has washable floors and walls. There is an industrial tumble drier and also an industrial washing machine, which is able to Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 20 wash clothing at appropriate temperatures. Residents are encouraged to bring their own laundry down and staff does their washing. The home has an infection control policy and staff have received training in this area, there are gloves and aprons available and all staff have all been issued with alcohol gel to help prevent the spread of infection. Cressage House DS0000062441.V367390.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 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents at the home are protected by the home’s recruitment procedures and they are supported by suitably trained staff EVIDENCE: The home employs a total of seven care staff, plus the home’s manager and the staffing rota showed that there was a minimum of two staff members on duty between 0730 – 2130. Between 2130 and 0730 there was one member of staff on duty who is awake throughout the night and is backed up by an on call staff member. The staffing numbers were discussed with the manager who felt that staffing levels were sufficient to meet residents’ needs, however the manager was reminded that she would need to keep staffing numbers under review to ensure that there were sufficient numbers of staff on duty at all times to meet residents needs. Residents spoken to told us that there was always someone around if they needed any help said they are well supported by staff at the home. We looked at the recruitment files of 2 staff members and both files contained Application form, 2 references, Job description, POVA check, CRB, Birth Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 22 certificate or Passport and copies of interview notes. Staff spoken with told us that their recruitment was thorough. We discussed training with the homes manager who told us that she has a training manual, which is sent to her each year by Portsmouth City Council, and this details courses available and she sends staff on appropriate courses as they become available. All staff has completed training in: medication administration, food hygiene, moving and handling, fire safety, first aid, COSHH and health & safety. Staff has also carried out additional training in mental health awareness, learning disability and challenging behaviour. Staff spoken to confirmed that they received a good induction and that they are provided with appropriate training in order to carry out their care tasks. Cressage House DS0000062441.V367390.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home and their views, and the views of other interested parties are sought on how the home is meeting residents needs. The health, safety and welfare of residents and staff are generally promoted and protected, however the home must obtain an in date certificate for the homes fixed electrical wiring. EVIDENCE: The registered manager has completed the Registered Managers Award and holds NVQ at level 4 in care. She has been managing the service for over 3 years and has the skills and experience to effectively manage the home. The manager has developed a quality assurance system and satisfaction surveys have been sent to residents, relatives, care managers and health care professionals. The manager co-ordinates responses and showed us the results of the last survey which showed that positive responses had been received. Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 24 Residents have yearly care reviews and care managers and health care professionals as well as residents and relatives are invited to attend, these reviews are used to monitor how the home is meeting its aims and objectives. There are monthly residents meeting and also monthly staff meetings. The provider has started to carry out monthly regulation 26 visits to the home and records of visits in April and May were seen, however there was no record of a visit in June. The provider must continue to carry out these visits to monitor the standards and outcomes for residents and provide a report, which must be kept at the home. The manager was aware of her responsibilities with regard to Health Safety and there is a fire risk assessment for the building. The fire logbook was inspected and all appropriate testing and checks have been recorded. The fire officer visited the home in January 2008 and noted 4 deficiencies in the fire arrangements; all of these had been rectified by the home with the exception of one, which is waiting for work to be completed. Appropriate certificates were in date for gas safety, fire alarms systems and equipment and private electrical equipment. The manage could not find a certificate for the home’s fixed wiring and she told us that she will follow this up with the provider. Cressage House DS0000062441.V367390.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 2 2 3 3 X 4 X 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 X 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Cressage House DS0000062441.V367390.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 YA1 Regulation 4 Requirement The registered person must review the Statement of Purpose/Service User Guide booklet to reflect any changes made to policy in the home and make it available in alternative formats. The home must ensure that any controlled drugs are stored in a controlled drugs cabinet that meets the legal requirements as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. To ensure that residents and staff are protected the home must obtain an in date certificate for the homes fixed electrical wiring. Timescale for action 31/08/08 2 YA20 13(2) 30/09/08 3 OP38 23(4) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000062441.V367390.R01.S.doc Version 5.2 Page 27 Cressage House Standard Cressage House DS0000062441.V367390.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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