Inspection on 18/09/06 for Speakers Court

This inspection was carried out on 18th 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Speakers Court 18/09/09

Speakers Court 22/06/09

Speakers Court 11/09/08

Speakers Court 31/01/06

Speakers Court 16/09/05

Speakers Court 23/02/05

Speakers Court 27/07/04

Similar services:

Ashlong House

Spring Lane Care Home

Avenues (The) (Neave Crescent)

Barrington Lodge Nursing Home

Beacon House Nursing Home

St Mary`s Convent & Nursing Home

1-3 Frederick Gardens

The Royal Star and Garter Home

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

CARE HOME ADULTS 18-65 Speakers Court St James`s Road Croydon Surrey CR0 2AU Lead Inspector Lee Willis Key Unannounced Inspection 18th September 2006 09:30 Speakers Court DS0000025838.V311913.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 Speakers Court DS0000025838.V311913.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. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Speakers Court Address St James`s Road Croydon Surrey CR0 2AU 020 8665 0745 020 8665 0745 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) SCOPE Ms Laura Charlotte Ainslie Care Home 7 Category(ies) of Physical disability (7) registration, with number of places Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow two specified service users aged 65 or over to be accommodated. 31st January 2006 Date of last inspection Brief Description of the Service: The five flats that make up Speakers Court are owned by Croydon Churchs Housing Association, but are managed and staffed by the registered charity SCOPE. The scheme is registered to provide personal support for up to seven younger adults with Cerebral Palsy and associated physical disabilities. Laura Ainslie, as the registered manager of the service, has been in operational dayto-day control for nearly two years. Situated around an enclosed courtyard these five purpose built flats are all self-contained and have there own separate entrances. Each of the flats consists of a large open plan lounge/kitchen area, separate bedroom, and en-suite toilet and bathing facilities. The flats have also been suitably adapted to be wheelchair ‘friendly’ and fitted with specialist moving and handling equipment to meet the occupants’ individual needs. Within the scheme there is a separate office, sleep-in room, kitchen, and toilet facilities for staff use. The schemes central location in the Broad Green area of West Croydon ensures local shops, cafes, restaurants, and banks are all within easy reach. The service does not have its own transport, but is relatively close to several main line bus routes, two train stations, and a tram stop. The scheme also has good links with local taxi/diala-ride companies and one occupant has their own car. Prospective service users and their reprensentatives are given copies of the homes Statement of Purpose and Guide, which includes fees they can expect to be charged for services and facilites provided. Fees currently stand at between £670-£1,200 per week. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process, which included a visit to the service, the Commission for Social Care Inspection (CSCI) has judged the scheme to have substantially more strengths than weaknesses with no significant issues identified in areas relating to the health and safety of the occupants or the management of the service. Key National Minimum Standards are generally met, although the manager recognises that there are still some areas of practice where the scheme could do better. The Commission remains confident the provider will manage weaknesses that have emerged well. This unannounced site visit was carried out on Monday morning between 9.45am and 1.00pm. During the course of this three and three quarter hour inspection a total of three occupants, two support workers, and the manager were all met. Three of these people were spoken with at length. The remainder of the site visit was spent examining the schemes records and touring the premises. As part of the pre-inspection process the CSCI sent out questionnaires to the scheme to distribute to amongst the people who use the service and their representatives. To date the Commission has not received any satisfaction comment cards in respect of this service or the schemes preinspection questionnaire. What the service does well: What has improved since the last inspection? Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 6 The over whelming majority of requirements identified in the schemes last inspection report have all been suitably addressed in a timely fashion. The schemes Statement of purpose and fire risk assessments of the premises are now reviewed on an annual basis and updated accordingly to reflect any changes. All the occupants care plans had been amended to include more specific guidance to enable staff to deal more effectively with incidents of challenging behaviour and minimise the likelihood of such significant events occurring. Arrangements the providers have with the external agency that supplies the scheme with all its moving and transferring equipment have recently been reviewed to ensure this specialist equipment is routinely tested by suitably qualified engineers. Finally, building work to improve the interior layout and design of all five of the schemes self contained flats is well underway and the manager is confidant the refit will have been completed within the next few months. The two occupants spoken with at length said they had both been invited to help design their new kitchens and decide what colour they wanted their flats to be redecorated. 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 DS0000025838.V311913.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 Speakers Court DS0000025838.V311913.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&2 Quality in this outcome area is good. This judgement has been made using all the available evidence. Prospective occupants and their representatives are provided with all the information they need to know about Blake Court before a decision is taken to move in. EVIDENCE: The manager was able to produce copies of the schemes Statement of Purpose and Occupants Guide on request. These documents had been reviewed in the past six months and up dated accordingly to reflect changes in provision. The revised version of the schemes Statement of Purpose/Guide contained the vast majority of information prospective service users and their representatives would need to know about the scheme, including fees charged for services and facilities provided, although the document did not contain any specific details about Scope arrangements for increasing fees. One occupant spoken with at length said they had been provided with an up dated version of the schemes Guide. The manager confirmed that the scheme remains fully occupied. Speakers Court DS0000025838.V311913.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 & 9 Quality in this outcome area is good. This judgement has been made using all the available evidence. Care plans remain fit for purpose but will nevertheless need to be improved to ensure staff know exactly what support each occupants requires to achieve their unique personal goals. Overall, suitable arrangements are in place to ensure occupants have opportunities to participate in all aspects of life in the home and to take responsible risks as part of an independent lifestyle. EVIDENCE: Two care plans sampled at random both contained detailed information about the individuals personal, social and health care needs, as well as specific guidance to enable staff to support these occupants manage risks associated with certain activities. However, the registered manager the conceded that although occupants care plans remained ‘fit’ for purpose they were not particular service user centred and lacked detailed information regarding the actual support each occupant needed to achieve their personal goals. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 10 The manager said she was instrumental in developing a new care plan format that would be in placed by 1st April 2007. Progress on this matter will be assessed at the schemes next inspection. The aforementioned plans had both been reviewed twice in the past twelve months and up dated accordingly to reflect any changes in need. These reviews had all been well attended by the relevant occupants, their keyworkers, the schemes manager, and where applicable the occupants next of kin, and Care managers. The manager said that none of the occupants had expressed a wish to participate in regular meetings about the schemes operation. Both the occupants spoken with at length said the staff were generally very approachable and felt occupants meetings were not necessary in such a small project. A comprehensive list of assessments that set out in detail all the action to be taken by staff to minimise identified risks were available from two care plans sampled at random. Speakers Court DS0000025838.V311913.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): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence. The scheme has sufficiently robust arrangements in place to ensure the opportunities occupants have to engage in age, peer and culturally appropriate activities of their choice, both at home and in the wider community, provide them with daily variety and stimulation. Dietary needs are well catered for and meals served nutritionally well balanced, providing daily variety and interest for the occupants. EVIDENCE: One occupant spoken with at length said they often attended services at a local Catholic Church. The manager confirmed that all three of the occupants who have expressed a wish to places of worship on a regular basis are actively supported to do so by staff. Occupants spiritual needs and religious beliefs are always recorded in their care plans. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 12 At the time of arrival it was noted that one occupant had gone away to stay with relatives, another occupant was attending a local day centre, and another had driven themselves to work. During the course of the visit another occupant went out shopping with staff. One occupant spoken with at length said they liked spending time alone in their flat during the day, and particularly enjoyed playing games on their computer. Another occupant said they still went swimming with staff on a regular basis and had recently been to see their favourite band in concert. The same individual went onto to say they enjoyed a very active social life and were seldom bored. It was evident from the entries made in the schemes visitors book that morning that staff had consistently asked them all, including the inspector, to sign this important record. Two occupants spoken with at length said they were not aware of any restrictions on visiting times. During the course of this visit the manager and another member of staff on duty at the time were observed on two separate occasions knocking on occupants doors to seek their permission to enter their flats. Scope has a clear policy on sexuality and the manager demonstrated a good understanding of occupant’s rights on this subject. The two occupants met said staff always helped them prepare the meals they had chosen to eat when they wanted them. A support worker was observed preparing a meal of sausage and mash for one occupants lunch in their flat. The occupant said they had bought the ingredients for the meal a few days before and was exactly what he had decided to have for their lunch that day. The individual went on to say that on the whole staff would help occupants shop and prepare the meals they wanted more or less when they wanted them. As a consequence of this very flexible and person centred approach of preparing meals the schemes does not publish a menu, although staff do keep a record of all the food consumed by the occupants to ensure diets are nutritionally well balanced. During a tour of one occupants flat their kitchen cupboards and fridge were well stoked with a variety of nutritious and correctly stored items of food. Speakers Court DS0000025838.V311913.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 & 20 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to ensure occupants receive personal support in the way they prefer and require, and their unique physical and emotional health care needs also recognised and met. Furthermore, occupants retain control of their own medication where appropriate and are protected, so far a reasonably practicable, from unnecessary harm or abuse by the schemes policies and procedures for handling medication. EVIDENCE: Two care plans examined in depth both contained manual handling assessments that set out in detail the support these individuals which each required to ensure their physical needs were continually met. Both the occupants spoken with at length said they could choose, within reason, what time staff support them to get up, go to bed, have a bath, and go out. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 14 Staff keep an up to date record of all the health care appointments occupants attend and one occupant spoken with at length said staff always accompany you to the GP’s surgery, hospital, dentist ect if you request assistance. The schemes accident book revealed that there had been no accidents involving occupants since the last inspection, although there had been a hospital admission, which the Commission had been notified about in a timely fashion. The manager was very aware that occupants have the right to make ‘informed’ decisions about how their own health care needs are managed, but was also very clear that she had a duty of care to ‘limit’ choice if she felt it was in the occupants best interests to do so. It was positively noted that the scheme maintains a separate incident book to record the occurrence of significant events involving occupants, which is kept secure in the office for reason of confidentiality. No recording errors were noted on medication administration sheets sampled at random. Stocks of medication held in one occupants flat were securely locked away in a kitchen cupboard. It was positively noted that based on a thorough assessment of individual occupants wishes and needs staff continue to actively support all those who are willing and able to self administer their own medication. These risk assessments were available on request, along with records of these occupants’ current medication regimes. The manager said staff continue to monitor this practice and always ask occupants if they have taken there prescribed doses of medication each day. Speakers Court DS0000025838.V311913.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 & 23 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficiently robust arrangements are in place to enable occupants and their representatives to feel any concerns they may have about the schemes operation are taken seriously and acted upon. Suitable arrangements are also in place to ensure the occupants are not placed at unnecessary risk of harm or abuse. EVIDENCE: Both the occupants spoken with at length said staff were very approachable and good listeners on the whole. The schemes complaints log revealed that one complaint regarding staff attitude had been made in the past eight months. This concern was partially upheld by the schemes manager following an internal investigation and prompt action taken to remind staff about their support worker responsibilities. This was achieved through supervision and team meetings. One occupant met said they were satisfied with the way their concern was handled. The manager confirmed that there had been no allegations of abuse made within the schemes in the past twelve months. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 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 the following standard(s): 24, 27, 28, 29 & 30 Quality in this outcome area is excellent. This judgement has been made using all the available evidence, including a site visit to the scheme. The new interior designs of occupants self contained flats ensures they live in a safe and comfortable environment that suits their individual lifestyles and so far as reasonably practicable maximises independent living. EVIDENCE: During a tour of the premises it was noted that building work to up grade the interior design of all the flats was well underway. The manager confirmed that all the flats would eventually been fitted with new kitchen units, shower facilities, flooring and intercom systems. It was positively noted that a comprehensive assessment of the risk associated with the on going building, which included the interim arrangements put in place to minimise these hazards had been established and was made available on request. One occupant met said arrangements had been made for them to move into another Scope project in the area for a few weeks while their flat was redecorated. The occupant said they had consulted about these interim arrangements and were satisfied with the outcome. Both the occupants spoken with at length said they had been fully involved in the process of designing Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 17 their new kitchens and had both helped choose the colour their flats would be redecorated. The manager confirmed the new kitchen units would be suitably adapted with lowered work surfaces and all manner of adjustable storage systems to meet the occupant’s physical needs. The temperature of hot water emanating from the bath in one flat was noted to be a safe 43 degrees Celsius at 11.45am. The manager said all the new showers will be fitted with preset, fail-safe and tamper proof thermostatic mixer valves that will ensure the hot water emanating from these outlets never exceeded a safe 43 degrees Celsius. Moving and transferring equipment noted in one occupant flat, who included an overhead tracking device, was fit for purpose and maintained in good working order. Each flat has its own washing machine that is capable of washing clothes at appropriate temperatures. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 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 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, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using all the available evidence. Sufficient numbers of suitably competent and trained staff are employed on a daily basis to meet the collective needs of the occupants. The schemes arrangements for recruiting new staff are sufficiently robust to ensure occupants are not placed at risk of harm from people who are ‘unfit’ to work with vulnerable adults. However, records of all new staffs induction training needs to be kept on the premises as proof that these individuals are now suitably competent to work unsupervised with the occupants. Occupants continue to benefit from being supported by a suitably competent staff team who are well supported and supervised/appraised at regular intervals. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager said that almost 100 of both her current permanent and bank staff had either achieved an NVQ level 2/3 or were enrolled on a suitable course. At the time of arrival two support workers and the registered manager were all on duty. The manager said current daytime staffing levels were adequate to meet the occupants assessed needs. That morning the manager had come in at short notice to cover a member of staff who had rang in sick. The manager said she ensures at least three members of staff are always on duty during the day and will often provide sickness cover as and when required. The duty rosters for September 2006 showed that two sleep-in members of staff continue to be employed at night, although the Commission has been formally notified about the provider’s proposal to review current nighttime levels. Records revealed that two new staff had been recruited since the schemes last inspection. Staff records in respect of these two individuals were examined in some depth and found to contain all the relevant information as care home is required to obtain when recruiting new members, including; job application forms; two written references; up to date Criminal Records (CRB) and Protection Of Vulnerable Adult register (POVA) checks; proof of their identifies; and Home Office approved work visas (where applicable). The manager confirmed that it is compulsory for all new staff to start their induction on their first day of employment and to have completed it within the first 6 months of that date. However, no records of the inductions started by the aforementioned new members of staff were available on request. The manager said it was not custom and practice for copies of new staffs induction checklists to be kept on the premises. Instead new recruits are expected to keep their own copies of their induction during their probationary period of employment. Documentary evidence was available on request to show that sufficient numbers of the schemes current staff team had received up to date training in a number of core areas of practice, including; fire safety, moving and handling; first aid; basic food hygiene; vulnerable adult protection, medication, and equal opportunities. Three staff files inspected, including one of the schemes most recent recruits, all contained documentary evidence to show they had each received at least three formal supervision sessions with a suitably qualified senior member of staff in the past seven months. Furthermore, the manager was well on course to ensure her entire staff teams job performance in the preceding twelve months would all have been appraised by the end of the year. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 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 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, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using all the available evidence. Occupants and staff continue to benefit from the managers open and inclusive approach to running the scheme. However, the satisfaction questionnaires developed by the providers to ascertain occupants views about the service they receive remain inadequate and will need to be improved to ensure all the relevant stakeholders, including the occupants and their relatives, can have their say about the quality of the service provided. The scheme has sufficiently robust health and safety arrangements in place, including fire safety, to ensure occupants; their guests and staff are not placed at risk of unnecessary harm. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 21 EVIDENCE: The schemes registered manager has now successfully completed the management component of her NVQ Level 4 and is three quarters of the way through the care component, which Laura is hoping to have completed by 1st April 2007. Progress on this matter will be assessed at the schemes next inspection. Documentary evidence was available on request to show the manager has undertaken a number of advanced level training in the past seven months to up date her knowledge and skills, including a four day long first aid course; risk assessing; health and safety; and a moving and handling teacher training course. The manager said staff meetings continue to be held at regular intervals. Record revealed the last meeting held in July 2006, was well attended, and covered a variety of relevant topics, including; medication practices, health and safety, and arrangements regarding the new refit. The manager demonstrated a good understanding of the importance of having good self-monitoring systems as a means of improving standards. Scope have developed a quality assurance system, but the manager felt the satisfaction questionnaires being used to ascertain service users and their representatives views about the standard of care being provided were not particularly accessible. The manager has agreed to develop far more occupant ‘friendly’ surveys and publish any feedback she receives by January 2007. It is recommended that the results of any quality assurance survey undertaken by the scheme are published in the occupants guide to make them available to all the relevant parties, including; prospective occupants, their relatives, care managers and the CSCI. Records showed that the schemes fire alarm system continues to be tested on a weekly basis and the last fire drill was undertaken in June 2006. The manager explained that this evacuation was the result of staff burning toast and that no problems were experienced during the unplanned exercise. The schemes fire risk assessment of the premises was last up dated in February 2006. Up to date Certificates of worthiness were available on request as proof that suitably qualified engineers had carried out periodic tests of the schemes fire alarm system, emergency lighting, and portable electrical appliances. A minor accident occurred during this visit and the manager demonstrated a good understanding of the schemes emergency first aid procedures and knew exactly where to locate the first aid box. The box was well stocked with all the relevant first aid materials to deal with such a minor injury. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 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 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 4 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 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 3 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 3 X 3 3 1 X X 3 X Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 23 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 YA35 Regulation 17(2), Sch 4.6(f) & 18(1) 12.3 & 24.1,2 & 3 Requirement Timescale for action 01/10/06 2. YA39 Records of the induction all new staff complete, as part of their probationary period of employment must be kept on the premises at all times. An effective quality assurance 01/01/07 system must be introduced and the results of any occupant/stakeholder holder surveys undertaken by the provider published on an annual basis. Previous timescale for action of 1st April 2006 not met. Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 24 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. Refer to Standard YA1 Good Practice Recommendations The occupants Guide to the scheme should contain more detailed information about payment arrangements for facilities and services provided, including reasons for any increases and periods of notice that should be given. The registered manager should have achieved the care component of her NVQ level 4 in Management and Care by 1st April 2007. The results of any quality assurance surveys undertaken by the scheme should be published in the occupants guide to ensure this information is available to any ‘interested’ parties, including; prospective occupants, their relatives, care managers, and the CSCI. 2. 3. YA37 YA39 Speakers Court DS0000025838.V311913.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston 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 DS0000025838.V311913.R01.S.doc Version 5.2 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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