Inspection on 07/08/08 for 53 Rutland Gardens

This is the latest available inspection report for this service, carried out on 7th August 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 53 Rutland Gardens Hove East Sussex BN3 5PD Lead Inspector Nigel Thompson Unannounced Inspection 7th August 2008 09:30 53 Rutland Gardens DS0000070619.V368952.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 53 Rutland Gardens DS0000070619.V368952.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. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 53 Rutland Gardens Address Hove East Sussex BN3 5PD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 328707 garry.cmg@btinternet.com www.caremanagementgroup.com Care Management Group Ltd Vacant Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 4th January 2008 Brief Description of the Service: 53 Rutland Gardens is a care home, which opened in August 2007. It is registered to provide personal care and accommodation for up to six people with learning disabilities. The home’s literature states that it ‘aims to provide care to people with some behaviours of a challenging nature associated with the autistic spectrum’. The home is owned and run by Care Management Group (CMG) which is a large national organisation. The home is a newly refurbished large semi-detached property situated in a quiet residential area of Hove. There is nearby access to some local amenities and public transport. A small car parking area is available at the home, although paid on street time restricted car parking is permitted in the surrounding areas. Accommodation is provided over three floors with some rooms situated on mezzanine levels ‘between’ floors. All rooms are for single occupancy with ensuite facilities. Communal space is provided on the ground floor and comprises a lounge to the front of the house and a dining room to the rear. The home provides personal care and support to people who are funded by Social Services. The home’s fees, as of 7 August 2008, range from £1000 £2300 per person per week. Written information is available on request from the home. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection took place over five hours in August 2008. It found that many of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was satisfactory. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to monitor care practices at the home and assess compliance with requirements made following the previous inspection. The focus was on the quality of life and outcomes for people who live at the home. Since the previous inspection a new manager has been appointed and his application to be registered is currently being processed by CSCI. On the day of the inspection there were five service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with two service users, two members of staff and the appointed manager and deputy manager. Information received in the Annual Quality Assurance Assessment (AQAA) and responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. What the service does well: The evidently committed and motivated management structure and dedicated support staff work hard developing and maintaining the stimulating, open and inclusive atmosphere within the home. Prior to moving in, prospective service users and their relatives receive relevant information and have the opportunity to visit the home in order to help them decide whether or not they would like to live there. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 6 On admission, all service users are provided with a copy of their terms and conditions of occupancy, outlining what the person can expect from the service. Nutritious meals, reflecting individuals’ likes and preferences, are provided and where appropriate service users are encouraged to help with the meal preparation. Staff have evidently developed close and effective relationships with local GPs, District Nurses and other associated professionals to help ensure that service users’ healthcare needs are met. What has improved since the last inspection? What they could do better: Despite previous concerns the service still needs to become more focused on delivering a person centred approach to care. This will help to ensure more consistency and continuity in the approach of staff when responding to the individual and often complex needs of service users. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 7 Care planning, including risk assessments and strategy guidelines must be reviewed and improved to ensure that service users’ identified healthcare and support needs are met by staff in a more structured and consistent manner. Regular reviews should be held involving each resident and, where appropriate, their relative or representative, to ensure that care plans accurately reflect an individual’s current and changing support needs. The review, including any agreed action points and future goals, should also be appropriately recorded. In certain areas of the home, including some service users’ bedrooms, walls and paintwork are looking ‘tired’ and in need of redecorating and generally ‘freshening up’. The badly stained carpets in the lounge and on the staircase should now be replaced. Staff must receive formal and structured supervision – one to one confidential discussion with their line manager regarding work practices and associated issues - on a regular basis. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The improved admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Comprehensive information relating to the service is made available to all prospective service users, their relatives and associated care managers. Relevant documentation including a Statement of Purpose ‘ and ‘Service User Guide’ was examined and found to be generally satisfactory, with evidence of amendments having been made to reflect the recent management changes. There have been three service users admitted to 53 Rutland Gardens since the previous inspection. An updated admission policy and procedure that was made available for examination contained details of the thorough assessment 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 10 process, undertaken by the organisation’s ‘Referral and Assessment Team’ and now evidently involving the Home’s manager, to identify an individual’s care and support needs. An ‘Initial Assessment of Need and Compatibility,’ is completed for each prospective service user. As well as personal details, reason for referral and background information, the comprehensive assessment includes sections relating to: ‘Care and support needs’; ‘Communication’; ‘Learning disability’; Physical/mental health needs’ and ‘Risk factors to self/others’. It was noted that in respect of at least one of the new service users a ‘Compatibility Assessment Tool’ had been completed. It contained comprehensive details regarding environmental factors – ‘Physical’, ‘Social’ and ‘Organisational’ – ‘Likes and Dislikes’, ‘Challenging Behaviour’, ‘Risk Assessments’ and ‘Personal Relationships’. The assessment was compiled from information provided by the Resource Managers at the individual’s previous residential service and Day Centre as well as a member of the ‘Behaviour Support Team’. The appointed manager confirmed that, prior to moving in, a prospective service user would be invited to visit the home to look around and get a feel for the place. During these visits the individual would also have the opportunity to meet with existing service users and members of staff. On moving in, a flexible trial period is provided to establish whether the individual’s assessed needs are able to be met and decide on their suitability for the home and their compatibility with existing service users. This was evidenced by positive comments received from a service user’s relative: ‘He has progressed and certainly seems to be very happy there.’ 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Care planning remains unsatisfactory and does not always enable staff to meet the variable support needs of service users in a structured and consistent manner. Systems for consultation and participation are generally effective and service users are encouraged and enabled to make decisions about their dayto-day living. EVIDENCE: Despite previous requirements and ongoing concerns regarding the standard of care planning within the home, it is evident from individual plans that were examined that many inconsistencies remain and little improvement has been made in this area. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 12 Individual care plans that were examined were found to be cumbersome and disorganised with information largely inaccessible. There was also little documentary evidence that plans are regularly and routinely reviewed and consequently do not reflect individual service users’ changing care and support needs. Further evidence of the inadequate reviewing and updating of care plans was provided by service users’ relatives, spoken with as part of the inspection process: ‘We have no problems with the actual care he receives although I have no idea what is in his care plan’. Having only been in his current position since March this year, the appointed manager describes the ‘overhauling’ of the care-planning system as ‘work in progress.’ However he is evidently aware of the significant shortfalls, particularly regarding risk assessments, staff guidelines and the reviewing process and is clearly keen to address them. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish, however they do not all benefit from appropriate educational and leisure activities. Menus are balanced and nutritious, reflecting individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan. They continue to be supported, as far as is practicable, to access activities and facilities, reflecting their individual needs, preferences and abilities. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 14 However in individual activity programmes that have been developed, prior to the current manager being in post, a variety of recreational and leisure activities had been identified which evidently do not actually happen. These included one service user: ‘…carrying out DIY around the house’ and on another day ‘going for a bike ride’, when in reality, according to the manager, he is not able to ride a bike and has no access to one. Community participation evidently remains a focus and staff confirmed that service users are encouraged and supported to attend day services, visit local shops, libraries, restaurants and other amenities. Service users are encouraged and supported to maintain family links. Staff confirmed that visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. This was supported by service users’ relatives, spoken with as part of the inspection process: ‘The staff always seem to be very kind, friendly and helpful when we visit’. ‘They keep us regularly informed about what is going on and we seem to be consulted about most things’. Menus are varied and balanced and are evidently based on service users’ identified likes and preferences. An alternative to the main meal is always available. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff work closely with service users, however, inconsistent care planning and reviewing systems mean that individual plans do not always accurately reflect changing health care and support needs. Service users are protected by improved policies and procedures in place for the control and safe administration of medication. EVIDENCE: The appointed manager emphasised the importance of staff developing close working relationships with individual service users and being aware of changes in mood or behaviour. In accordance with their personal care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 16 As previously documented, and as confirmed by the appointed manager, work is ‘ongoing’ within the home to develop and implement more person centred care planning (PCP). Inconsistencies with the current system, including unsatisfactory guidelines, management strategies and reviewing procedures, inevitably have an impact on the level of appropriate care and staff support provided to meet changing personal healthcare needs. However it is understood that these issues are being addressed and as a consequence a full time ‘Person Centred Planning Co-ordinator’ has recently been appointed. 53 Rutland Gardens has evidently been prioritised, within the organisation, and the implementation process for the new ‘comprehensive’ care planning system will commence in early October. All service users are registered with local GPs and have access to other health care professionals, including district nurses, speech and language therapists and dentists, as required. All medical appointments with, or visits by, health care professionals are appropriately recorded. Improved, up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. All staff responsible for administering medication have received training, as part of their comprehensive induction programme, and are individually assessed and authorised to do so. The manager confirmed that, following risk assessments, no service user currently self-administers their own medication. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure ensures that service users and staff feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through relevant staff training and policies and procedures relating to abuse and safeguarding vulnerable adults. EVIDENCE: The home has developed and implemented a clear, simple and concise complaints policy and procedure, for the benefit of service users, staff, relatives and other visitors to the home. All complaints are recorded and include actions taken and outcomes achieved. The manager confirmed that close working relationships and effective communication and consultation provides adequate opportunities for any concerns to be raised and discussed before they become complaints. Service users, their relatives and members of staff, spoken with as part of the inspection process, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 18 It was noted that there have been no concerns or complaints recorded by the home since the last inspection. The home has produced detailed policies and procedures, relating to adult protection and abuse, including a whistle blowing policy. These documents have evidently been reviewed, in accordance with the multi agency guidelines for the protection of vulnerable adults (Safeguarding adults). The manager confirmed that all care staff have undertaken appropriate training regarding abuse awareness and procedures relating to ‘Safeguarding Vulnerable Adults.’ This was evidenced by training records examined and supported through discussions with staff. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The service is accessible, safe and suitable for its stated purpose. Service users benefit from accommodation that is comfortable, generally well maintained and furnished and decorated to a reasonable standard. EVIDENCE: During my ‘guided tour’ of the premises it was evident that the generally well maintained décor and adequate furniture and furnishings continue to provide a comfortable, safe and pleasant environment for service users. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ rooms, reflecting individual taste, preference and interests. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 20 Identified maintenance requirements are evidently documented and addressed, as necessary. However it was noted in certain areas of the home, including some service users’ bedrooms, that walls and paintwork were looking ‘tired’ and in need of redecorating. As discussed with the manager, the institutionalised labelling of drawers and wardrobes does little to enhance the appearance of the rooms. The badly stained carpets in the lounge and on the staircase should be replaced. Service users, with staff support as necessary, are evidently responsible for keeping bedrooms clean and tidy. From the sate of certain rooms it is evident that this is not routinely happening and the situation should be more closely monitored. Infection control policies and procedures are in place and clearly adhered to and, on the day of the inspection, with the above exceptions, levels of cleanliness and hygiene throughout the home were found to be generally satisfactory. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is generally sufficient trained and competent staff on duty to meet the assessed needs of the service users. However staff do not currently receive formal supervision. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: Through discussion with the manager and care staff, it is evident that sufficient staff are employed to meet the current assessed support needs of service users and to ensure consistency and continuity of care. The deputy manager confirmed that staffing levels are closely monitored and are directly linked to the service users’ identified levels of dependency. A duty rota has been developed and implemented to detail the staff on duty at any given time and their designation. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 22 Appropriate core skills training is provided, including first aid, food hygiene and fire safety. This was confirmed through discussions with staff and evidenced by training records examined: ‘There is always plenty of opportunity for training here’. However it was evident from discussions with the manager and staff that formal and structured staff supervision has ‘slipped’ and is not being currently provided on a regular basis. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. Their best interests are safeguarded by adequate and effective quality monitoring systems. EVIDENCE: As previously documented, the appointed manager has been in his current position since March 2008. He is experienced and evidently competent to run the home. As well as having a degree in Psychology and a Masters Degree in Substance Misuse, he has also trained as a Cognitive Behavioural Therapist and recently achieved the Registered Manager’s Award (RMA). 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 24 There are some positive signs that, as previously documented, ongoing issues and concerns are now being acknowledged and addressed. Although having only been at the home for six months, it is hoped that the manager, with the able support of a very competent deputy manager, dedicated staff team and a newly appointed line manager (Regional Director), will continue to sustain and build on the improvements already made. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. He added that training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. This was also confirmed through discussions with staff and evidenced by training records examined. Effective quality monitoring systems, including satisfaction questionnaires, are in place. The views of relatives and other stakeholders in the community are also routinely sought. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 26 X 27 X 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X 3 3 X 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(1)(2) Requirement It is required that all service users have an up to date and person centred plan of care in place. To ensure that care staff have detailed information regarding the action that is to be taken to meet the personal, support and healthcare needs of service users, in a structured and consistent manner. Plans must be regularly reviewed and updated to reflect individual changing needs, wishes and preferences. (Previous timescale of 29.02.2008 not met) It is required that service users are enabled and supported to pursue appropriate DS0000070619.V368952.R01.S.doc Timescale for action 30/11/08 2. YA14 16 (2) (m) 30/11/08 53 Rutland Gardens Version 5.2 Page 27 2. YA24 23 (2) (b & d) 3. YA36 18 (2) social and recreational activities, reflecting their individual choice and interests. It is required that all areas of the home are kept reasonably decorated and well maintained. It is required that all staff receive regular, recorded supervision. 30/11/08 30/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 53 Rutland Gardens DS0000070619.V368952.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!