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Inspection on 16/09/05 for Speakers Court

Also see our care home review for Speakers Court for more information

This inspection was carried out on 16th September 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All three of the occupants met during this inspection said they liked living at Speakers Court and were especially impressed with the permanent members of staff, who always treated them with kindness and respect. The interaction between the occupants and staff on duty at the time of this visit, which included the new manager, appeared to be extremely cordial and relaxed. On the whole the staff team are suitably trained to carry out their duties and the vast majority have now achieved a National Vocational Qualification in care. One occupant said the best thing about having your own self-contained flat with a front door means you can close it whenever you want. Furthermore, it was evident from care practises observed, as well as comments made by the occupants, that staff continue to actively encourage and support the occupants to maintain and develop their independent living skills, as well as make informed decisions about their life`s. The self-contained flats remain suited for there stated purpose as they have all been suitably adapted to meet the physical needs of the occupants to ensure their independence is maximised.

What has improved since the last inspection?

The approach of the new manager appears to be a very open and inclusive one. Laura Ainslie demonstrated a good understanding of her new role, and in particular her responsibilities regarding new admissions and vulnerable adult protection issues. The new manager is also very keen to delegate more tasks amongst her staff team and encourage them to take on more responsibility for the day-to-day running of the project, including supervising colleagues and monitoring health and safety.

What the care home could do better:

CARE HOME ADULTS 18-65 Speakers Court St Jamess Road Croydon Surrey CR0 2AU Lead Inspector Lee Willis Unannounced 16 September 2005 13:25 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 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 Stationary 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. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Speakers Court Address St Jamess Road, Croydon, Surrey, CR0 2AU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8665 0745 020 8665 0745 SCOPE Care Home 7 Category(ies) of PD Physical Disability (7) registration, with number of places Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: A variation has been granted to allow two specified service users aged 65 or over to be accommodated. Date of last inspection 23 February 2005 Brief Description of the Service: Speakers Court is owned by Croydon Church’s Housing Association, and managed and staffed by the registered charity - Scope. The project is registered with the Commission for Social Care and Inspection to provide accommodation and personal support for up to seven adults with Cerebral Palsy and a broad range of associated physical disabilities. Laura Ainslie is the projects new manager and is currently in the process of applying to register with the Commission, subject to a fit person interview. Speakers Court is attached to St James church and is in keeping with the style of the surrounding architecture. Situated around an enclosed courtyard these five purpose built flats are all self-contained and have there own front doors, open plan lounges/kitchen areas, bedrooms, and en-suite toilet and bathing facilities. All the flats are wheelchair accessbile and have been provided with suitable environemntal adaptions and disability equipement to meet the individually assessed needs of the occupants. There is also a seperate office/sleep-in room, kitchen and toilet for staff use. Located relatively close to the centre of Croydon the scheme is well placed for accessing a wide variety of local amenities, including shops, resturants, and public transport links. East Croydon train station, the new tram link and numerous bus stops are all situated relatively close to Speakers Court. The project continues to support the occupants to maximise their independence and to have as much control over their lives as is reasonably practicable. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 13.25 on the afternoon of Friday 16th September 2005 and was finished within two and a half hours. Three service users were met during the course of this visit, of whom two were spoken with at length. Since April 2005 the Commission has received four comment cards in respect of this service, all of which had been completed by the occupants. The majority of this inspection was spent talking with the new manager, a student on work experience, and as previously mentioned, half the occupants currently residing at Speakers Court. The remainder of the visit was spent examining records and touring a couple of the flats with the occupant’s consent. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: What has improved since the last inspection? The approach of the new manager appears to be a very open and inclusive one. Laura Ainslie demonstrated a good understanding of her new role, and in particular her responsibilities regarding new admissions and vulnerable adult protection issues. The new manager is also very keen to delegate more tasks amongst her staff team and encourage them to take on more responsibility for the day-to-day running of the project, including supervising colleagues and monitoring health and safety. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 6 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. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 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 standard(s) 1 & 2 Speakers Courts Statement of purpose provides prospective occupants and their representatives with the vast majority of information they need to know about the suitability of the project, although it will need to be updated to reflect recent changes. EVIDENCE: In the main the projects Statement of purpose provides prospective new occupants and their representatives with the vast majority of information they need to know about the project. The document was last reviewed in January 2005, although the new manager is aware that it will need to be up dated again to reflect recent staff changes, both at the home and in the company as a whole. Progress on this matter will be assessed at the next inspection. As the project has not had any vacancies for sometime its admissions procedures could only be assessed in principle. The new manager was very aware of her responsibilities in this area and was clear about the projects admissions criteria. The manager also said that all the existing occupants would be consulted about the placement of a new prospective occupant. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 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 standard(s) 6 Care plans accurately reflect service users personal, social and health care needs, although it is recommended that a far more person centred approach to care planning is introduced to ensure staff have all the information they require to plan for and meet the occupants needs. EVIDENCE: Care plans are clearly based on individual assessments and cover every aspect of each occupant’s personal, social and health care needs. These plans have been used to great affect in the past, although the new manager believes there is room for improvement and will be reviewing the existing format. Having discussed this matter with the new manager it was agreed that care plans could indeed be made more person centred and include more detailed information about each occupant’s personal goals. Progress on this matter will be assessed at the next inspection. It was positively noted that all the occupants care plans had been reviewed in the past six months and up dated accordingly to reflect changing needs Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 10 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 standard(s) 12 & 17 The number of social, educational and vocational opportunities the occupants have to engage in if they choose appears to be extremely varied. Dietary needs are well catered for, nutritionally balanced, and clearly based on personal preferences and choice. EVIDENCE: It was evident from comments made by the occupants met during this visit that they have very active lives and are free to choose what they do and when they do it. On arrival the vast majority of the occupants were out either working, attending clubs, shopping or visiting relatives and friends. One occupant said that since the projects last inspection he had obtained a freedom pass from the Local Council, which entitled him to free travel on public transport in the Croydon area. He went onto say that he regularly caught the bus to going swimming with staff once a week and do his weekly food shopping. The manager said that the occupants continue to do their own food shopping on a weekly basis and make their own arrangements with staff on duty at the time to help them prepare meals in their own flats. Consequently, published Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 11 menus are not necessary, although staff still appropriately maintains a detailed record of the food actually consumed by the occupants. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 12 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 standard(s) 19, 20 & 21 Suitable arrangements are in place to ensure that occupants physical and emotional health care needs are identified, planned for and met, although the reporting of significant events to external professional bodies must be improved to ensure the occupants rights and best interests are safeguarded. In the main the projects policies for dealing with medicines protects the occupants, so far as practicable, from harm, although a far more comprehensive assessment of the risks associated with one occupant selfmedicating needs to be undertaken. The occupants are actively encouraged to plan for ageing, illness and death, and their wishes on this highly sensitive matter are clearly listened too and recorded. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 13 EVIDENCE: The projects accident book revealed that there had been one accident involving an occupant since Christmas. No major injuries were sustained and staff on duty dealt with the matter at the time. There have also been two ‘significant’ incidents involving occupants during the last six months, which although recorded, neither was reported to the Commission. The new manager is reminded that any event, which clearly has an adverse affect on the health and welfare of the occupants, must be reported to the Commission without delay. Appropriate action was taken by the new manager to deal with both these incidents at the time, although a more detailed assessment needs to be carried in respect of one occupant continuing to self-medicate. The project is commended for supporting the occupants to, so far as reasonable practicable; retain as much control over their medication as possible. All the flats have been provided with a lockable space for the occupants to store their medication safely. It was positively noted that sufficient numbers of the current staff team have completed a Distance-learning course in the safe handling of medication. One occupant said Scope had been extremely supportive helping him find out about and get in touch with the relevant professionals to set up a Living Will. The project is highly commended for ensuring occupants wishes regarding ageing; illness and death are listened to and acted upon. Furthermore, it demonstrates Scopes commitment to ensuring staff are precluded from having any direct involvement in making or benefiting from occupants Wills, in accordance with the national Minimum Standards of good practice. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 14 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 standard(s) 22 & 23 On the whole occupants spoken with were confident that any concerns they had about the projects operation would be listened to and acted upon, in accordance with Scopes complaints procedures. The projects vulnerable adult protection and abuse prevention measures are in the main ‘suitably’ robust to ensure the service users are, so far as ‘reasonably’ practicable, protected from abuse, neglect and/or harm, although more specific guidance for dealing with incidents that challenge the service must be established. EVIDENCE: In the past twelve months the project has not received any formal complaints about its operation. The new manager is familiar with the projects complaints procedure and said that all complaints/concerns brought to her attention would always be recorded in the projects complaints log, including any action taken in response. One occupant said all the staff working at the project were extremely approachable and he felt able to talk to his keyworker or manager about any concerns he may have. There have been no allegations of abuse made within the project or staff referred for possible inclusion on the Protection Of Vulnerable Adults register (POVA) since its creation in 2004. The new manager was aware of her responsibilities regarding vulnerable adult protection and has dealt with adult protection issues in the past as a manager of another residential care home. As previously mentioned in another section a significant incident involving an occupant and member of staff recently occurred at the project and the new manager has agreed to include more specific guidance for staff to follow in order to minimise the risk of similar incidents reoccurring in the future. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 15 Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 16 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 standard(s) 24, 26 & 27 The layout of the self-contained flats, which are all suitably adapted to meet the occupant’s physical needs, ensures everyone lives in an extremely homely environment that maximises their independence. However, the interior décor of the flats is looking rather dated and a time specific programme to redecorate the project should be established to improve its overall appearance. The temperature of hot water emanating from the projects water outlets must be more effectively controlled to minimise the risk of occupants being scalded. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 17 EVIDENCE: There have been no significant environmental changes made to the project since its last inspection in February 2005. Since the last inspection a meeting has been held between the owners of Speakers Court - Croydon Churches Housing Association, and senior managers representing Scope, to ensure both groups are clear about their maintenance, repair and redecoration responsibilities. The new manager said CCHA’s maintenance team are in the main reasonably efficient when it comes to carrying out both routine and more urgent maintenance and repair work around the place, although she is aware that there have been problems in the past. Having been granted permission by several of the occupants to view their flats, and discussed the matter with them and the new manager, the overwhelming consensus of opinion expressed about the interior décor of the flats was that they all needed redecorating. All the people spoken to on the subject, including the occupants and staff, believed that none of the flats had been decorated for at least the past five years or more. Some of the wallpaper and paintwork in the three flats viewed was definitely looking rather dated and shabby in places. The new manager has agreed to liaise with her line manager and CCHA, who are ultimately responsible for the up keep of the premises, in order to establish a time specific rolling programme to redecorate the flats. The projects weekly water temperature log revealed that hot water used in baths never exceeds 43 degrees Celsius, which is two degrees lower that the maximum agreed between the project and the Commission. However, using a thermometer to test the temperature of water emanating from a hot tap attached to the bath in flat No#8 it was found to be an extremely unsafe 49 degrees Celsius at 14.45. All the projects thermostatic mixer valves must be checked as a matter of urgency to ensure they are of the type that is preset tamper proof and fail-safe. The temperature of hot water used in baths must remain constant and never exceed 45 degrees Celsius to minimise the risk of occupants being scalded. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36 Sufficient numbers of suitably experienced and competent staff are employed to meet the health and welfare needs of the occupants, although staffing levels should be reviewed to ensure they continue to be adequate. Furthermore, insufficient numbers of the current staff team are suitably trained to recognise, prevent and report abuse to ensure the occupants are, so far as reasonably practicable, protected from harm. EVIDENCE: A student on a weeklong work experience placement was spoken to at length during this inspection. The student said she had enjoyed here time observing the practises of the staff employed to work at the project and confirmed that in accordance with her terms and conditions of her placement she had not been permitted to support occupants with any of their personal care needs. The student also said she was very impressed with the standard of care provided by the staff at Speakers Court and thought the atmosphere was always friendly and relaxed. The manager stated that well over 50 of the projects staff have already achieved a National Vocational Qualification in care, Level 2 or above, in accordance with the Governments training targets for support workers and National Minimum Standards. The registered providers remain committed to Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 19 staff training and should be commented for their positive approach to ensuring all staff are suitably qualified and competent to perform their duties. There have been no changes to staffing levels since the last inspection. Two members of staff, excluding the manager who is always supernumerary to staff /occupant ratios, were both on duty at the time of arrival. These two members of staff were both replaced in the afternoon by staff working the late shift. Both the manager and student on work experience remained supernumerary. Some written and verbal comments made by occupants both before and during this inspection, suggested that current staffing levels were not always adequate to meet their needs, especially early in the morning. The new manager was already aware that concerns had been raised by some of the occupants regarding staffing ratios, and as a result has already decided to review current arrangements. The new manager said she will be considering changing her own shift patterns to make them more flexible and/or employing an additional third member of staff to cover ‘peak’ periods of activity on a more frequent basis. Progress on this matter will be assessed at the projects next inspection. The project has experienced relatively low rates of staff turnover in the past six months and no new members of staff have been recruited in this time. The new manager is familiar with Scopes recruitment procedures and is very knowledgeable about her responsibilities regarding the new Protection Of Vulnerable Adults (POVA) register. The vast majority of the projects staff team have attended a number of core training courses that are relevant to the work they are perform, including fire safety and prevention, first aid, moving and handling, basic food hygiene, medication, and equal opportunities. However, the new manager concedes that insufficient numbers of the current staff have received any training in recognising, preventing and reporting vulnerable adult abuse. The new manager continues to ensure that each member of staff has at least one formal supervision with their line manager every two months or so. As acknowledged by the projects former manage, with so many members of staff to supervise on a bi-monthly basis Laura should give serious consideration to giving more responsibility to her senior staff team and delegating this task amongst them. Progress on this matter will be assessed at the next inspection. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 & 42 In the main the homes health and safety arrangements are sufficiently robust to ensure potential risks to service users, their guests and staffs health are, so far as reasonably practicably, minimised. Nevertheless, the homes gas installations still need to be tested by a suitably qualified engineer on a more frequent basis to ensure it complies with health and safety regulations. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 21 EVIDENCE: The projects new manager, Laura Ainslie, has only been in post for a few months, but based on comments made by occupants and staff she has clearly settled in very quickly. The new manager has over five years experience working in a managerial capacity with vulnerable adults with a wide variety of needs, including physical and learning disabilities, as well as sensory impairments. Laura is on course to achieve her registered managers award by the end of the year (2005) and arrangements have already been made for her to commence her National Vocational Qualification training in care (Level 4) by the beginning of 2006. The manager is aware that she must submit an application to the Commission to register as the projects manager, subject to a ‘fit’ person interview with London’s Central Registration Team. The manager has recently undertaken a number of training courses to up date her knowledge and skills including, diversity and equality, multi-agency working and dealing with behaviours that challenge. There are clear lines of accountability within Scope and the new manager says her line manager is always on hand to offer support and advice as and when required. The projects fire records show all the occupants and staff on duty at the time responded well to the fire alarm being sounded and promptly evacuated the building when some toast was burnt in a flat in April 2005. An up to date Certificate of worthiness was in place as evidence that a ‘suitably’ qualified engineer had checked the projects electrical wiring in the past five years. The manager was aware that it needed to be done again by the end of this year. Periodic checks of the projects fire alarm system, extinguishers, portable electrical appliances and mobile hoists, had all been carried in the past twelve months. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 1 x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Speakers Court Score x 2 2 4 Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 23 NA 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 20 Regulation 13(2) (4) Requirement Timescale for action 1/11/05 2. 23 13(4) & 17(1)(a), Sch 3.3(q) 13(4) 3. 27 4. 35 13(6) & 18(1), Sch 2.4 A far more comprehensive assessment of the risks associated with an occupant continuing to self-medicate must be carried out and a detailed risk management strategy established setting clearly what action should be taken by staff to minimise identified risk/s. Care plans must contain more 1/11/05 specific guidance for staff to enable them to deal more effectivley with potentially challenging incidents. All the projects thermostatic 1/10/05 mixer valves must be checked as a matter of urgency and suitably adjusted and/or replaced to ensure water temperatures for baths and showers remains at a contant 43 to 45 Degrees Celsius. Valves must be of a type that are preset, tamper-proof and fail safe. Sufficient numbers of staff need 1/01/06 to receive training in recognising, preventing, and reporting vulnerable adult abuse. Documentray evidence of this training must be avialable on request. Version 1.40 Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Page 24 5. 42 13(4) The projects periodic gas installations or Landlords test is nearly two months overdue and must be checked by a suitably qualified engineer. An up to date Certificate of worthiness must be forwarded to the Commission as proof of compliance. 1/10/05 6. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 6 24 33 36 37 Good Practice Recommendations The current care plan format should be reviewed and a more person centred approach to care planning considered. A timespecific rolling programme to redecorate the premises should be established. The projects current staffing levels should be reviewed and adjusted accordingly to reflect changing needs/wishes. Sufficient numbers of the projects senior staff team should be suitably trained to supervise their colleagues. The new manager should have at least started her NVQ Level 4 in care training by the end of 2005. Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 25 Commission for Social Care Inspection Croydon, Kingston & Sutton Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 Speakers Court G53-G53 S25838 SpeakersCourtUI V184203 160905 .doc Version 1.40 Page 26 - 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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