Inspection on 01/03/07 for Dartford Road (16-18)

This is the latest available inspection report for this service, carried out on 1st March 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dartford Road (16-18) 25/05/05

Dartford Road (16-18) 13/12/04

Dartford Road (16-18) 09/06/04

Dartford Road (16-18) 23/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Dartford Road (16-18) 16 - 18 Dartford Road Bexley Kent DA5 2AZ Lead Inspector Maria Kinson Unannounced Inspection 1st March 2007 09:45 Dartford Road (16-18) DS0000038185.V326535.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 Dartford Road (16-18) DS0000038185.V326535.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. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dartford Road (16-18) Address 16 - 18 Dartford Road Bexley Kent DA5 2AZ 01322 559856 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) dartfordrd@mcch.org.uk MCCH Society Limited vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd September 2005 Brief Description of the Service: 16-18 Dartford Road is a care home, which provides care for up to five adults with learning disabilities. The home has been open since September 1999 and is operated by the Maidstone Community Care Housing Ltd (MCCH). The building comprises of two semi-detached houses, which were converted into one house. The people living in the home share a large lounge/dining room, two smaller rooms for activities, a conservatory, kitchen, three bathrooms and a laundry room. There are five single bedrooms, one on the ground floor and four on the first floor. At the rear of the property there is an enclosed garden, which is wheelchair accessible. The home is situated on a busy road, within walking distance of a small parade of shops and a local bus service. Access to the home is via a sloping path or driveway. The commission was not able to obtain information about the fees charged by this home. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 1st March 2007 and was unannounced. The inspector spent nine hours in the home speaking to service users, staff and one visitor. All of the communal areas and a selection of bedrooms were viewed. Staff were observed supporting people to walk or change their position, to eat at mealtimes and to undertake activities. Care, medication, money, health and safety and staff recruitment and training records were examined. Written feedback about the service was obtained from three relatives, two service users and one social care professional. There were five people living in the home at the time of this inspection. What the service does well: The arrangements for admitting new people into the home were good with opportunities to visit and stay in the home before making a decision to move in. The people living in the home were supported to attend health care appointments and specialist advice was requested when necessary. Staff assessed potential risks and developed strategies to avoid people being harmed. The food provided in the home was varied and service users helped staff to plan the weekly menus. Relatives were able to spend time in the home with their family member and some relatives supported staff to keep the grounds tidy. Relatives said that staff always provided appropriate care and support for their family member and kept them informed about significant events. The home had not received any formal complaints but two concerns were followed up and addressed promptly. Staff spent time talking with the people living in the home and supported them to undertake activities that they enjoyed. Staff were able to attend relevant training sessions and gain new qualifications and skills. The staff on duty had a good understanding of their role and were knowledgable about service users needs and preferences. One social care professional said the manager and staff were “very skilled and resourceful”. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although contracts provided clear information about the level of support and facilities provided, service users did not know how much they were paying to live in the home. This information should be made available to the people living in the home and their representatives. It was not clear when some of the records seen were developed or if they were still relevant as they were not dated or signed. Medication was well managed overall but some medicines that were left over from the previous months supply were not recorded on the new medication administration record. Some of the guidance provided for staff about medication was old and should be updated. Health and safety issues were good overall but the mains electricity installation was reported to be “unsatisfactory” and the area near the back door was damaged and taped down. Fire drills were taking place regularly but the dates and times were known to staff, so they did not provide an accurate picture of how staff would respond if there was a fire. Money and valuable items were stored securely and good records were maintained about money kept or used by the people living in the home. Staff must ensure that similar records are kept for gift vouchers. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 7 Care was taken when recruiting staff to ensure that they were suitable to work with vulnerable adults. New staff must not be allowed to commence work in the home until the manager has adequate proof from head office that all of the necessary checks have been undertaken. 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. Dartford Road (16-18) DS0000038185.V326535.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 Dartford Road (16-18) DS0000038185.V326535.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): 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that were thinking of moving into the home were supported to view the facilities and meet the other people that lived and worked in the home. Contracts did not include information about fees. This information will help service users and their representatives to decide if the service offers value for money. EVIDENCE: The manager was preparing a picture booklet about the home. This book will provide basic information, in a suitable format, for the people using the service. Photographs of the home, staff and local places that service users visited were included in the guide. A copy of the guide should be supplied to the commission once complete. The manager had received an individual contract for each of the people living in the home. The contacts did not include information about fees and some were not agreed or signed by the service user or their representative. See recommendation 1. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 10 Since the last inspection one new person had moved into the home. An application for residence was completed and the funding authority provided a copy of the joint assessment form. The manager attended meetings with the prospective service user to discuss their individual needs and preferences and to obtain the views of relatives and care staff. The main issues discussed during the meeting were recorded. The service user visited the home on five occasions before moving in. These visits provided an opportunity for the service user to meet staff and the other people living in the home and to view the vacant bedroom and facilities. During the visits staff assessed the service user to see if they thought they would be able to meet their needs and to establish if they would get along with the other people living in the home. The service user looked happy and settled. Dartford Road (16-18) DS0000038185.V326535.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and personal preferences were outlined in the records held in the home. Staff encouraged the people living in the home to exercise personal choice and retain control over their lives, where possible. Action was taken by management to identify hazards and establish ways to minimise the risk of harm to service users or staff. EVIDENCE: The care records for two service users were examined. The file for the person that was admitted to the home since the last inspection included a pen portrait, guidelines about managing specific health issues and information about the persons preferred morning routine. Information was very person centred stating the persons preferences for bathing and times for getting up and going to bed. The file did not include an up to date individual plan for the person but it was possible to establish what care they required from the Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 12 information available. If staff consider the information listed above forms part of the support plan it must be signed, dated and reviewed regularly. See recommendation 2. The other file included similar information about the person’s individual needs but also had a list of the persons strengths and needs and a support plan. The plan was updated by staff regularly and was formally reviewed with the service user, their relatives and other professionals once a year. The records maintained by staff showed that most of the previous goals had been met. Some of the people living in the home had difficulty communicating and were only able to make staff aware of their preferences and choices through gestures and facial expressions, others were able to make simple choices with support from staff. Staff knew what service users liked and disliked and were familiar with the ways that people indicated their dissatisfaction. Staff were seen offering people choices about what they ate, if they wanted to accompany them on trips and what they watched on television. Risk assessments were seen in both of the files examined. Staff had identified potential risks such as road safety issues when the service user was out of the home and had developed clear strategies to minimise the risk of injury to the service user or others. One health care professional said she was very impressed with the way the manager “had considered all of the information” about her client and “had acted on any risk areas”. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home received a varied choice of food to meet their needs and tastes and were supported to spend their free time doing the things they enjoyed. EVIDENCE: Some of the people living in the home were engaged in activities when the inspector arrived. Throughout the day staff supported people to complete puzzles, watch their favourite television programmes and music DVD’s and use some of their personal items. The staff on duty demonstrated excellent interpersonal skills engaging the people using the service in conversation, keeping them informed about what was happening and sitting alongside them whilst they completed small tasks so that they could watch. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 14 Some of the people living in the home attended local day centres and colleges. Service users were supported to pursue personal interests and undertake activities of their choice in the home and community. Discussions with staff and examination of the records indicated that some of the people living in the home had attended clubs, a forum for older people, visited relatives, attended church services, car and shopping trips and enjoyed aromatherapy sessions in recent weeks. The home had its own transport. The home has several lovebirds, which were housed in the conservatory because of the weather. The home had recently installed an aviary in the garden and were planning to transfer the birds in the warmer weather. Relatives said they were able to visit the home at anytime and said they always received a warm welcome when they visited. Some relatives said they “popped” in unannounced or “just turned up” and nothing was ever any different. Their family member “always looked very smart” and “seems happy”. Some relatives said they were able to tell that their family member liked living in the home because they were always eager and happy to return to the home after visits or told them “to go home” when they visited. Staff encouraged relatives to take their family out, to contribute ideas and suggestions, attend meetings and parties and to help to keep the home and grounds tidy. Some of the people living in the home required a lot of support with personal care. Staff were aware of the need to promote independence in the activities of daily living and were seen encouraging people to do things for themselves where possible. Staff were supporting one of the people living in the home to prepare and make her favourite hot drink. Although some challenges were encountered during this process staff had found ways of overcoming the problems by purchasing a different teapot. Staff developed a weekly menu, which included one dish chosen by each of the people living in the home, a roast meal and another dish that was liked by all of the service users. Regular drinks were offered and one service user made some of her own drinks with support from staff. Dartford Road (16-18) DS0000038185.V326535.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff worked in partnership with other agencies to meet people’s health care needs. Medication was stored safely and was administered according to people’s needs and preferences. EVIDENCE: Guidelines were in place to monitor long- standing health issues and staff arranged for the people living in the home to see their GP when they were unwell or when new concerns were identified. Other professionals from the community learning disability team had assessed some of the people living in the home and provide advice and guidance for staff when requested. Four comment cards were sent to health and social care professionals that were in regular contact with the home. One comment card was returned to the commission. The respondent said that staff always met service users health care needs and maintained their privacy and dignity. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 16 Before staff administered medication they attended medication training and completed a practical assessment to see if they had understood the training and were competent. A medication procedure was kept in the home and local guidelines were developed in 2004 for staff to follow when ordering and receiving medication in the home. Guidelines had also been developed to advise staff about how people liked to take their medication such as on a spoon or at a specific time of the day. Storage facilities were satisfactory and suitable records were maintained for medication received, administered and sent for disposal. Medicines were well managed overall but staff must remember to carry forward any medication left over from the previous months supply and should review and update the homely remedies agreement and local guidelines. See requirement 1 and recommendation 3. Dartford Road (16-18) DS0000038185.V326535.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had good systems in place to protect the people living in the home and for responding to complaints or concerns. EVIDENCE: The home had a comprehensive complaints procedure, which included a timescale for responding to concerns and contact details for the commission. Most relatives said they knew how to make a complaint and who to speak to if they had any concerns about the service. The service had not received any formal complaints in the period since the last inspection but a concern raised by a relative in the questionnaire sent out by the home and a concern raised by a relative during a visit were addressed promptly. The commission has not received any concerns or complaints about this service. Staff had a good understanding of abuse and said they would report concerns or allegations to senior staff. The home had not made any referrals to the local adult protection team in the period since the last inspection. Good systems were in place to ensure that personal money was kept securely and that all incoming and outgoing money could be accounted for. Valuable items such as passports and bankbooks were recorded but some gift vouchers that one person had received as a present were not recorded. See requirement 2. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and comfortable. EVIDENCE: The home was well decorated and furnished. There was a variety of communal space and bedrooms were highly personalised. Since the last inspection three bedrooms, one bathroom and the hallway, stairs and landing had been redecorated and the front of house was repainted. New carpets had been fitted in the lounges, one bedroom and the hallway, stairs and landing on one side of the house and a new table and chairs had been purchased. Work had been undertaken to make the garden safer and to improve access. The faulty electrical socket and the gas installation work identified in the previous report was now satisfactory. The heating on one side of the house was not working. The boiler had been assessed and staff were awaiting further information about repairs. The Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 19 people living in the home spent most of their day in the warmer part of the home and staff were heating the bedrooms with portable heaters prior to people going to bed. The washing machine was also awaiting repair. The commission was advised in writing that all of this equipment was working on 20/03/07. The only issue that required attention was an area near the back door that was taped down due a leak from the sink unit in the kitchen. See requirement 3. The home was clean, tidy and free of unpleasant odours. Since the last inspection the manager had added various cleaning tasks to the shift planner to ensure that all areas were cleaned regularly. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The training and support provided by the company helped staff to meet people’s needs. Staff recruitment procedures were thorough but records maintained in the home did not always provide adequate evidence of this. EVIDENCE: 50 of care staff had attained a NVQ qualification in care and all of the remaining staff were currently undertaking this programme. Since the last inspection five members of staff had transferred to other homes or resigned. Some vacant posts had been filled and one post had been advertised internally. Temporary staff were used to cover vacant posts and staff sickness. Continuity of care was maintained by using bank staff that were familiar with the home or the same agency staff where possible. Two relatives expressed concerns that some agency staff did not have “the necessary skills” to care for their family member. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 21 The commission had agreed with the Registered Person that staff records could be held centrally if a form outlining all of the information and checks that were undertaken in respect of staff was kept in the home for inspection. Two forms were examined. The agreed form was in use but parts of the form such as the criminal record bureau disclosure number, an explanation of gaps in employment history and the reason why the applicant left their previous post were incomplete on one form. See requirement 4. A provider relationship manager from the commission was undertaking additional checks at the company’s head office twice a year. The most recent audit was undertaken in January 2007 when all of the files examined were found to comply with regulations. Staff said they were able to attend relevant training sessions and the records seen reflected this. During the past year some members of staff had attended NVQ, moving and handling, supervision, epilepsy, food hygiene, first aid, fire safety, medication and health and safety training. The home received a copy of the training programme which listed all of sessions that were planned and staff were encouraged to attend. The frequency of staff meetings had improved and staff were receiving regular supervision. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 22 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, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home was well managed and led. Staff worked in partnership with relatives and other professionals to maintain service users safety and improve their quality of life and wellbeing. EVIDENCE: Since the last inspection the manager had resigned and a new manager had been appointed. The new manager had worked in the service for many years and knew all of the people living in the home and their relatives. The manager has a vocational qualification in care and management at level 3 and was undertaking the registered managers award. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 23 The manager’s application to become the Registered Manager for the service is currently being assessed by the commission. Positive feedback about the management of the service was received from staff and visitors. One social care professional said, “the manager and staff provide a very warm and caring and homely environment, whilst adhering to professional standards”; “I am very impressed with the manager and staff”. Relatives said the manager and staff were “very supportive” and “extremely caring “. Staff felt supported by the manager and senior staff and said they were always treated fairly and given an opportunity to put forward ideas or suggestions about the way the home was run. There was an up to date fire risk assessment and the fire alarm system and fire safety equipment was serviced at regular intervals. Staff attended fire safety training sessions and regular drills were taking place. It is recommended that fire drills are unannounced so that the manager and senior staff can assess how people respond. See recommendation 4. A random check of health and safety reports and inspections was undertaken. All of the records except the mains electricity installation and Legionella report were found to be satisfactory. Work was undertaken to address the Legionella report but it was not clear what action, if any was taken to address the mains electricity installation, which was reported to be “unsatisfactory”. The manager telephoned the maintenance department during the inspection but was not able to obtain the information required. See requirement 5. The manager had developed a questionnaire for obtaining feedback about the service from relatives and health and social care professionals. The results from the questionnaire that was sent to relatives in 2006 provided staff with useful information about activities, meetings, visiting arrangements and the environment. Relatives were advised in writing about the results and any action that had been taken by staff to address their concerns. This initiative is commended. Accident forms were examined. Six accidents occurred in the home in 2006 and two accidents in 2007. Staff had recorded relevant information about the accident on an accident form and in the individual’s diary. Senior staff analysed accidents and took action where possible to prevent a reoccurrence. Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The Registered Person must ensure that the balance of medicines carried forward each month is recorded on the administration record. The Registered Person must ensure that a record is maintained about all valuable items held for safekeeping. The Registered Person must ensure that the area that leaks around the sink and the area that is damaged as a result of the leak is repaired. The Registered Person must ensure that the agreed form for recording recruitment checks is completed in full for all members of staff. The Registered Person must advise the commission in writing about the action that was taken to address the concerns identified in the mains electricity installation report. Timescale for action 21/06/07 2. YA23 17 21/06/07 3. OP24 23 19/07/07 4. YA34 17 21/06/07 5. YA42 23 19/07/07 Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 26 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 YA5 Good Practice Recommendations The Registered Person should ensure that contracts include information about the fees charged by the service and are agreed and signed by the service user or their representative. The Registered Person should ensure that all records are signed and dated. The Registered Person should review and update the homely remedy agreement and local medication guidelines. The Registered Person should ensure that fire drills are unannounced. 2. 3. 4. YA6 YA20 YA42 Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Dartford Road (16-18) DS0000038185.V326535.R01.S.doc Version 5.2 Page 28 - 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. 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