Inspection on 14/09/06 for Palmer Crescent (1)

This inspection was carried out on 14th September 2006.

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

The inspector found 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Palmer Crescent (1) 10/11/05

Palmer Crescent (1) 21/07/05

Palmer Crescent (1) 15/12/04

Palmer Crescent (1) 12/07/04

Palmer Crescent (1) 12/02/04

Palmer Crescent (1) 17/12/03

Palmer Crescent (1) 05/09/02

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Palmer Crescent (1) 1 Palmer Crescent Rushmoor Ottershaw Surrey KT16 0HE Lead Inspector Sandra Holland Unannounced Inspection 14th September 2006 10:30 Palmer Crescent (1) DS0000013439.V302604.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 Palmer Crescent (1) DS0000013439.V302604.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. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Palmer Crescent (1) Address 1 Palmer Crescent Rushmoor Ottershaw Surrey KT16 0HE 01932 874478 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) Welmede Housing Association Ltd Ms Christina Liddington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-64 Years 10th November 2005 Date of last inspection Brief Description of the Service: 1 Palmer Crescent is a large detached bungalow that has been extended to provide accommodation and care to six people who have learning disabilities. The home is owned and managed by Welmede Housing Association Ltd, with the staff being employed by North Surrey PCT. The home has a large lounge and a smaller lounge, a good sized, homely kitchen and a well maintained, enclosed garden to the rear. All bedrooms are for single occupancy, with two having en-suite facilities. There is a newly refitted shower room and a separate large bathroom which is due to be refurbished in the near future. The home provides a comfortable and homely environment for the service users to live in. The home has its own vehicle to facilitate service users activities and there is ample parking to the front of the building. The fees at this service are £1604.00 per week. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2006 to June 2007 and was carried out under the Commissions “Inspecting for Better Lives” programme. Mrs Sandra Holland carried out the inspection over seven and a half hours. Ms Emma Chandler, Team Leader was present representing the service and Ms Christina Liddington, Registered Manager arrived later. A full tour of the premises was carried out and a number of records and documents were sampled including service users’ individual plans, medication records and staff files. All six service users were met with and one visitor and four staff were spoken with. As the inspector was not able to directly communicate with some of the service users, their responses and reactions were observed, in addition to their facial expressions and body language. The home was supplied with a pre-inspection questionnaire which was completed and returned. Some of the information supplied in the questionnaire will be referred to in the report. The inspector would like to thank the service users and staff for their hospitality, time and assistance. What the service does well: The service users receive a high level of individual support to meet their specific needs and are encouraged by staff to be independent and to make their own choices. Most of the staff have worked at the home for a number of years and have developed a very good knowledge and understanding of each service users’ support needs, likes and dislikes. The home is spacious and is well equipped to meet the mobility needs of the service users. It is decorated and furnished in a homely style, with a level access to almost all areas, to enable service users to be as independently mobile as possible. The home is clean, bright and freshly aired, which is commendable, given the complex needs of the service users. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 7 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 Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of any prospective service user would be fully assessed before they moved into the home. EVIDENCE: The copies of the home’s statement of purpose and service users guide which are held by CSCI are outdated and the manager agreed to supply and forward new copies of these. Five of the six service users who live at the home have lived there for many years, since the home was opened as a newly built service, having transferred from a large, local hospital which had closed. The sixth service user has also lived at the home for seven years. The manager was able to describe the assessment process that would be carried out to ensure that the home could meet the needs of a prospective service user and that any new service user would be compatible with the existing group. As most prospective service users are funded by a local authority, a full needs assessment would be carried out under the care management process and a copy of the assessment would be obtained the manager stated. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive individual plans and assessments of risks are in place to guide staff to the support and care needed by each service user. Due to the level of their needs, support in decision making is required by all of the service users. The decisions that are taken reflect the known preferences of the service users. EVIDENCE: Service users’ individual plans were seen to be comprehensive and provide staff with effective guidance as to the complex support and care needs of each service user. The individual plans detail all aspects of service users’ daily lives including communication needs, personal care needs, social and religious support needs, healthcare needs and mobility needs. It was pleasing to see that service users’ individual plans are regularly reviewed to ensure they reflect current and changing needs. For those service users who present with challenging behaviour, specific behaviour management guidelines have been drawn up. These guide staff to Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 10 recognise when these behaviours might arise, how to prevent them and how to manage them if they do. For service users with communication difficulties, a “communication passport” has been developed by their key-worker and a speech and language therapist. This provides staff with comprehensive information as to the communication methods used by service users, their likes and dislikes and the most effective way to approach the service user. Staff advised that most of the service users are only able to make their own decisions at a limited level, such as what to wear or their choice of what to eat, due to the level of their disabilities. For other, more major decisions, service users need the support of their representatives or staff, who use their well developed knowledge of the service users’ likes, dislikes and needs. From the individual plans it was clear that any risks to service users have been assessed, recorded and where possible, minimised. A number of risk assessments were seen for each service user and these reflected their needs, behaviours and differing activities and lifestyles. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully supported to take part in a wide range of activities and to be members of their local community. Staff enable service users to maintain their family links. Well-balanced meals are provided to meet the needs of the service users. EVIDENCE: It was evident that service users are well supported to have a range of occupational and leisure activities to take part in. A chart of everyone’s activities is displayed in the office and details of these are also contained in the service users’ individual plans. The activities listed include attendance at day services, aromatherapy, swimming, snoozelem sensory sessions, Get up and Go sessions, shopping, disco’s and bingo. Staff advised that a reflexologist also visits regularly and visited the home on the day of inspection. The home has a large television and music centres to provide entertainment at home. The team leader advised that the home has a people carrier vehicle to transport service users and that staff are allocated to ensure that at least one Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 12 driver is available on every shift. A spacious, level garden is available to service users and this is equipped with tables and chairs and a swinging seat for service users, staff and visitors to enjoy. Staff advised that all service users have family supporters with varying degrees of contact. One service user goes out regularly with his family, another is able to go to visit his family occasionally and two service users go out with their families when they come to visit. Staff advised that they also support service users to keep in touch with their families by sending family birthday cards and assisting service users when their family phone them. Two CSCI feedback cards were completed and returned by relatives of service users and both had additional comments added, which were very complimentary about the support and care provided at the home. Staff advised that although it is difficult for service users to make new friends because of their communication difficulties, they are supported to meet new people, often at the day services attended. It was pleasing to hear that five of the six service users have been on holiday to the West Country this summer. Service users went on holiday with staff in two separate groups, staff advised. Service users were having their lunchtime meal during the course of the inspection and were observed to be enjoying their meal, which appeared wellbalanced and appetising. Staff encouraged service users to make their own choices and to be as independent as possible in their meal preparation and when eating. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in the way they prefer whenever possible and their healthcare needs are very well met. The amount of medication in the home did not accurately match the record held. EVIDENCE: Staff advised that although the service users have communication difficulties, they were still able to convey a preference for the way that they are supported and by whom. Where these preferences are noted, they are recorded to guide staff and are respected whenever possible. Service users’ rooms and the home generally, are well-equipped with specialist equipment such as hoists and easy access showers, to meet the service users’ needs and preferences. The manager advised that specialist support, such as from physiotherapists or speech and language therapists, is sought as soon as required, to meet any changing needs of the service users. It was clear from speaking to staff and from the records in the individual plans, that service users’ healthcare needs are well met. A number of healthcare professionals are involved in the support Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 14 of service users, including general practitioners (GP’s), chiropodist, physiotherapist, speech and language therapist and dentist. Staff advised that they have learnt to recognise changes in the service users’ behaviours, which may be an early indication of a change to the service users’ health. It was pleasing to see that very detailed assessments have been drawn up as a guide to service users’ physical and mental health. These would be very useful to any new staff, who had not yet developed a detailed knowledge of the service users. Staff advised that medication in the home is provided by a local pharmacy and is supplied in original packaging. The medication records and storage facilities were seen and the quantities held were checked against the record held. It is of concern that the stock of three medications held, did not accurately match the record held. The manager stated that a small stock of these medications had been carried forward from the previous delivery, but this had not been recorded. It is required that accurate records are maintained of all medication received into the home, administered to service users or returned to the pharmacist, in order that an audit trail can be followed. The manager advised the inspector prior to the issue of this report that the excess medication mentioned above had been returned to the pharmacy. An immediate requirement has been made regarding Standard 20. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No complaints have been recorded, but staff are alert to any changes in service users’ moods which may indicate unhappiness. Staff are aware of their role in the protection of service users. EVIDENCE: As the service users have communication difficulties and cannot make a verbal complaint, they are reliant on staff observing changes in their behaviours, facial expressions or body language, to express any unhappiness or discontent. Staff stated that they are very aware of any change in a service users’ mood and would quickly look for the cause of this. The home’s complaints procedure was available in a written format although staff advised that the service users would not be able to access the procedure, even if it was made available in alternative ways. The complaints record was seen and no complaints had been recorded. The team leader advised that any concerns that are raised are addressed immediately by the person in charge or by the manager and a visitor confirmed this. Staff spoken to stated that they have received training in the safeguarding of adults, are aware of the vulnerability of the service users and are aware of their role in the protection of service users. Staff stated that they would have no hesitation in reporting any concerns about abuse or suspicions of abuse, to the manager or team leader. Staff were also aware that they could report Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 16 these to a senior manager if they felt that appropriate action was not being taken. The manager stated that in the event of any incident of, or allegation of abuse, the home would follow the Surrey Multi-Agency procedure for safeguarding vulnerable adults. A copy of this procedure was available in the home and was the most recent version. The team leader advised that she had been required to implement the Surrey policy in the past, when working at another service. Money is held for safekeeping on behalf of service users staff advised, to enable them to make purchases and pay for hairdressing and towards outings and holidays. A receipt is obtained for all purchases, which is kept to ensure that service users’ monies are appropriately used and these are logged in the record kept for each service user. To safeguard service users and staff, the monies held are checked at each shift handover by the staff going off and the staff coming onto their shift. The record and the monies held were checked and accurately matched. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well suited to the needs of the service users, is decorated and furnished in a homely style and all areas were clean and freshly aired. EVIDENCE: The home, a purpose built bungalow, is situated in a small residential close and is surrounded by similar properties. It is well suited to the needs of service users, with all rooms opening from a wide, bright corridor. All areas are level and doorways, shower and toilet facilities are all wheelchair accessible. A requirement was made at the last inspection that the standard bath must be replaced with an easy access bath as recommended by the minimal handling advisor, but this has not yet been carried out. The manager stated that most service users are currently using the recently refitted shower room and arrangements are being made for the standard bathroom to be completely refurbished. The manager anticipates that the work to refit the bathroom will be started within five to six weeks. This is urgently required as the manager stated that at least two service users prefer baths to showers. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 18 Six service users are accommodated at the home and each service user has a single bedroom, furnished and equipped to meet their individual needs and tastes. One bedroom has a large en-suite shower room and another bedroom has an en-suite toilet facility. All other bedrooms are provided with a wash hand basin. The communal areas are spacious, with a lounge/dining room, a separate, smaller lounge and a large kitchen equipped with a table and chairs, enabling all service users to eat together in a family style. It is commendable that the home was freshly aired, attractively decorated and furnished in a comfortable and homely style, given the complex needs of the service users. Only two shortfalls were noted. As mentioned previously, the standard bath is to be replaced by an easy access bath and arrangements for this are already underway. A requirement was also made at the last inspection, that improvements must be made to ensure the safety of service users going out of the patio door in the lounge, as the step presented a tripping hazard. It was required that a handrail be fitted but this has not been carried out. The manager stated that in practice, service users usually go into the garden using the door in the hall which is fitted with a ramp, and the use of the patio door is not likely to occur during the winter months. As this may present as a hazard in the warmer weather, it is required that either a handrail is fitted as previously required, or a means of safeguarding the patio door is established, to prevent service users falling over the step. All areas of the home were very clean and appeared hygienic, with handwashing facilities, liquid soap and paper towels provided in all appropriate places. Staff were observed to use personal protective equipment including gloves and aprons, to prevent the spread of infection. The manager advised that the home has a contracted collection of its clinical waste and an appropriate bin is stored outside. A laundry room is situated very practically near the service users’ bedrooms and bathrooms, which prevents laundry having to be carried through the home. The room is well equipped and the washing machine has appropriate settings. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are effectively supported by a stable, experienced and trained staff team. The recruitment of staff must be more closely monitored. EVIDENCE: From the information provided in the pre-inspection questionnaire, it is clear that the service users are supported by a small, stable team of staff, most of whom have worked at the home for many years. Staff advised that they take part in all roles within the household, including personal support, shopping, cooking, domestic and laundry tasks and activities. Staff were observed to interact with service users in an informal and relaxed, but appropriate manner. Staff were sensitive to service users’ needs and offered personal support in a discreet way, promoting privacy and dignity. As most of the staff have been employed at the home for a number of years, or have transferred to the home from other homes within the organisation, few staff have been recruited recently the manager stated. The files of the most recently recruited or transferred staff were seen and it was clear that the Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 20 recruitment of staff must be more closely monitored. It was disappointing that no recruitment documents were held in the home for a recently employed member of staff, although these were later brought to the home from a nearby North Surrey Primary Care Trust (NSPCT) office. For another member of staff who had transferred from a home in the group, the Criminal Record Bureau (CRB) disclosure which was held was not valid, as it related to a previous employer, and CRB disclosures are not transferable. The manager stated that a small number of staff have achieved, or are registered to undertake, a National Vocational Qualification (NVQ) to level 2 or 3 in care. Two members of staff have achieved NVQ level 2 in care and one member of staff has almost completed level 3. It is that recommended that further staff should undertake an NVQ, in order that the target of fifty per cent of trained staff can be achieved. The NSPCT which employs the staff working at the home, has produced a Training Opportunities Guide. This has been supplied to the home to advise staff of the training courses that are available and the dates these are to be carried out. Individual training records are held in the home for each member of staff, and the manager maintains a training plan to ensure that training is updated as required. From the records seen, it was clear that some of the staff have undertaken training required by law, including fire safety and first aid, and other training to develop their knowledge and skills, such as infection control. From the information provided in the pre-inspection questionnaire, it is evident that further staff require training in first aid, to ensure that a member of staff with this training is available for each shift. The service users are supported by a staff team of mixed gender which reflects the service user group, although the cultural and racial diversity of the staff group is not reflected in the service user group. Requirements have been made regarding Standards 34 and 35 and a recommendation has been made regarding Standard 32. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced and well qualified person and the health and welfare of service users is promoted. A quality assurance system needs to be developed and should be supplied to all those involved in the support of service users. EVIDENCE: The manager stated that she is a qualified nurse and has undertaken and achieved the NVQ Registered Manager’s Award (RMA). The manager advised that she has worked at the home since it was opened. It was evident that the manager is very experienced in the support and care of service users with complex learning disabilities and is well qualified for her role. Due to the level of their disabilities, the service users are not able to convey their views of the quality of the service provided, but a survey of relatives views was carried out in 2005 and only two of the surveys were returned the manager advised. The manager advised that there is currently no Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 22 organisational, quality assurance system being carried out at homes within the group. It is required that an annual quality assurance system is established, and that it is supplied to all those involved in the support of service users, to obtain an independent view as to how the home is meeting the needs of the service users. This is particularly important, given that service users are not able to give their views. The health, safety and welfare of service users is promoted and protected. Information supplied with the pre-inspection questionnaire confirmed that maintenance checks and servicing of equipment is carried out regularly and to the required frequencies. This included testing and checking of fire safety equipment, fire drills and alarm testing, checking of the gas and electrical supplies and specialist maintenance checks on the hoists in the home. A requirement has been made regarding Standard 39. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 23 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 3 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 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 2 X X 3 x Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 Requirement Timescale for action 17/10/06 2 YA24 23 3 YA27 23 4 YA34 19 & 17 Schedules 2&4 The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Specifically, the amount of medication held must accurately match the record held. The registered person must 19/01/07 ensure that a risk assessment is carried out regarding the trip hazard posed through stepping out of the patio door in the lounge, and that a step down from the patio door and a handrail be put into place to reduce the risk of service users falling out of the door. The registered person must 19/01/07 ensure that the standard bath in the bathroom is replaced with an assisted bath as recommended by the minimal handling advisor. The registered person must not 17/10/06 employ a person to work at the care home unless (a) the person is fit to work at the care home and (b) the information and documents specified in Schedule DS0000013439.V302604.R01.S.doc Version 5.2 Palmer Crescent (1) Page 25 5 YA35 18 6 YA39 24 2 have been obtained in respect of that person. The records relating to persons employed at the care home as specified in Schedule 4, must be retained in the care home. Staff must receive training to 19/01/07 enable them to fulfil their role. Specifically, staff must receive first aid training to ensure that at least one member of staff on each shift is qualified in first aid. The registered person must 19/01/07 establish and maintain a system for reviewing and improving the quality of care provided at the home. The system must provide for consultation with service users and their representatives and a copy of the report from any review must be provided to CSCI and made available to service users. 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 Refer to Standard YA32 YA39 Good Practice Recommendations It is recommended that further staff should undertake NVQ training to ensure the National Minimum Standard of 50 trained staff is achieved. To effectively assess how the home is meeting the needs of the service users, any system of reviewing the quality of the service provided should be supplied to all those involved in the support of service users. Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Palmer Crescent (1) DS0000013439.V302604.R01.S.doc Version 5.2 Page 27 - 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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