Inspection on 05/07/05 for 1-2 Downer Court

This inspection was carried out on 5th July 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1-2 Downer Court 20/07/07

1-2 Downer Court 02/08/06

1-2 Downer Court 18/01/06

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

CARE HOME ADULTS 18-65 1-2 Downer Court 1-2 Downer Court Wilson Avenue Rochester ME1 2SA Lead Inspector Sue McGrath Announced 5 July 2005 10.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 1-2 Downer Court Address 1-2 Downer Court Wilson Avenue Rochester Kent ME1 2SA 01622 769100 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MCCH Society Limited Tracey Mateer Care Home 8 Category(ies) of Learning Disability (7) registration, with number Learning Disability - over 65 (1) of places 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 1-2 Downer Court provides accommodation for eight residents with learning disabilities and high dependency needs. All of the accommodation is situated on the ground floor and has attractive gardens to the rear of the property. The home is located in a residential area close to shops and local amenities. The Registered Provider from the 01-04-05 is MCCH Society Ltd.. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 5th July 2005 between 10.00 and 15.00. Two inspectors were in the home and the main focus of the inspection was on the general environment and the well being of the residents. During the inspection documentation and records were read, including care plans. A tour of the building was undertaken and many of the residents were spoken to. Time was also spent talking to staff and members of the management team. A high number of comment cards were received from family members and other visiting professional and all gave positive feedback. Families who replied were all happy with the level of care offered. What the service does well: What has improved since the last inspection? The home has recently purchased new cookers, dishwashers and other equipment for the kitchen and laundry. Extra fire extinguishers and fire blankets are in place. Some new furniture has been ordered. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Prospective service users are currently not provided with the information they need to make an informed choice about moving into the home. Service users benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Service users and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service though contracts stating terms and conditions are not currently supplied. EVIDENCE: The home does not have a current Statement of Purpose or a Service User Guide that reflects the recent change in registered provider. The new provider (MCCH Society Ltd) took over the management role on the 1st April 2005. The manager stated that this work is currently being undertaken and that it would be ready for the next inspection. Discussion took place over the contents and format of the proposed documents. The home had not admitted any new service users recently but did have a copy of MCCH policies and procedures on the admission of service users. The manager was able to discuss in detail what information she would require before she could make a judgement on whether the home would be able to 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 9 meet the needs of any new service user. Several visits to the home would be encouraged to ensure assessed needs could be met and to ensure that the prospective service user fitted in with the other service users. In reality the home will not be admitting any new service users, as some of the rooms are very small and service users currently in the two shared rooms would be offered a single room. The home currently provides care to service users with learning disabilities, physical disabilities and some behavioural difficulties. Their needs were well documented in the care plans with good guidance recorded on how to meet these needs. Overhead hoists were provided for service users who had been assessed as needing them. One service user is currently going through the process of assessment due to being transferred to a nursing home, as her main needs have changed. Training records of the staff on duty at the time of the inspection and observation of their practise and discussion with them, demonstrated they had the skills and experience to care for the residents at that home. Contracts / statements of terms and conditions were currently being written by the new provider. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Service users have clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Service users are enabled to take reasonable risks within the homes risk assessment management strategies so that as far as possible they can maintain an independent lifestyle. Service users privacy is protected by a confidentiality policy with which staff are familiar. EVIDENCE: The care plans were viewed and found to be comprehensive. Due to the level of disability of the service users, it was not possible for them to be fully involved in the drawing up of their individual care plans. Evidence was seen that other professionals including epilepsy nurses, speech therapists and care managers were involved in preparing these documents. The home does operate a key worker system and each service user is allocated a dedicated member of staff. Individual preferences in daily routines were well documented in care plans and were confirmed by staff during discussion with the inspectors. The level of choice that each service user could make was varied 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 11 but it was clear that a lot of effort from staff and from the Speech and Language Therapist had enable service user to be as fully involved as possible. With some of the service users it was only possible to offer the choice of two items, however staff were very aware of individual likes and dislikes. Communication passports had been tried but had proved unsuccessful. Service users participation in the day to day running of the home was discussed, but again with the level of disability in the home, it was difficult to assess the level of understanding and the amount of input service users could contribute. Meetings had been undertaken but these had proved unsuccessful. Detailed risk assessments were seen which identified specific risks to individual residents and gave clear direction to staff to enable them to minimise the risk. Staff spoken to were aware of the policies about confidentiality and the manager confirmed that this was an important part of new staffs induction. Records were stored in the dining area of the home due to the lack of office space. This issue was discussed with the manager and service co-ordinator as not only did it impinge on service user space it was not private and secure. It was strongly advised that when a room became available it was used as a secure office. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16,17 Resident’s benefit from having the opportunity for personal development with their daily living skills though staff shortages mean that appropriate levels of leisure activities are restricted. Residents also benefit from being part of the local community. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The resident’s benefit from the appetising meals and balanced diet offered by the home. EVIDENCE: It was clear throughout the inspection that service user were given the opportunity to maximise their potential for independence and fulfilment wherever possible. Some of the service user had more potential than others 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 13 and this was recognised by the manager and staff group. With some of the service user the main priority was in maintaining living skills. Some of the service users were encourage to participate in household skills whilst other were content to watch staff perform these tasks. Due to the level of disability current service users were prevented from seeking employment or engaging in further education, however daily care notes recorded that where possible the opportunity to participate in in-house activities facilitated by staff were encouraged. In house activities included painting, arts and crafts, cookery and manicure and make up sessions. Some service users benefit from Reflexology session, Aromatherapy session and three have Indian Head Massages. The manager stated that these have proved very successful in reducing stress levels amongst some of the service users who appeared far more relaxed after the treatments. The service user pays for these treatments. The home does confirm the qualifications of the therapists prior to these sessions being provided and advice is also sought from the service user’s GP. The home does have an activity co-ordinator visit the home, but this only for one and a half hours per week. Outside activities included bowling session, cinema and sensory rooms, meals out and swimming. Low staffing levels had affected the amount of activities offered and this needs to be addressed. The high level of staff sickness and 3 full time vacancies mean that agency or bank staffs are frequently used (see standard 33). The manager did confirm that one permanent member of staff always worked with an agency/bank member of staff. The home is currently arranging either holidays or days out according to the preferences of the service users. Visiting times are flexible, but again due to lack of space, visiting cannot be done in private. Home visits can be arranged if requested. The home is now being encouraged to visit other MCCH establishments to try to encourage friendships. Policies and procedures were in place regarding relationships. The manager confirmed the home enjoyed a good relationship with its neighbours. Comments from families who replied to the commission’s comment cards indicated they were happy with the service offered. The daily routines are based on individual needs and the home had a very family orientated feel to it. Staff were seen to communicate appropriately and effectively with the service user and interacted well with them. Meal times in particular were very flexible. Meals were offered three times a day with a range of snacks and drinks being available at all times. Menus were varied and normally chosen by a different service user each day. No evidence could be found of any nutritional assessments being carried out and service users were not being weighed regularly, due to the home not owning any scales. It will be a requirement that both of these issues are addressed. One service user had pureed food and this was appropriately served. Staff were seen to be giving good support with eating. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users have clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure both physical and emotional health needs are met. Changes are recorded and acted upon. Health needs are met and service users have full access to all professional health care services as required. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff were seen to provide good support and discussion with them evidenced that service user wishes were respected in relation to dress and appearance. Times for rising and retiring were flexible and according to the need and preference of the individual service user. Technical aids and equipment, including ceiling hoists and specialist chairs, were provided as recommended by professional assessment. Care plans indicated that specialist support and advise as needed from physiotherapist, occupational therapists and speech therapist had been sought and their advice had been incorporated into the daily living plans. The home was currently actively seeking further advise from a physiotherapist regarding one service user in particular. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 15 The health and welfare of the service user was monitored in the daily care plan with access to professional health care services as and when required. Tissue viability was of a high importance to staff and evidence was seen that staff had a good knowledge skin integrity and the prevention of pressure sores. Pressure relieving mattresses and cushions were in place. The homes administration of medication was assessed and was found to be in line with the guidelines from the Royal Pharmaceutical Society of Great Britain. Records were maintained appropriately and protocols were in place with regard to PRN medication. Both the manager and assistant manager had completed an accredited training coursed in the administration of medication and regularly assessed other staff to ensure their competencies were maintained. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Service users are protected from abuse by the home’s has a robust complaints system and Adult Protection Policy and procedures. EVIDENCE: The home has a new complaints policy with the new provider and staff are currently digesting all the new procedures. The procedure was seen to be robust and include a whistle blowing policy. The manager was aware of the Protection of Vulnerable Adults register (POVA). There had been no complaints in the past 12 months. The home had received some positive compliments this year. The home has adopted Kent and Medway’s procedure on Adult Abuse and all staff were trained in this subject. Discussion with staff confirmed they had a good knowledge of Adult Abuse. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) ,24,25,26,27,29,30 Whilst service users have access to safe and comfortable indoor and outdoor communal areas, the home is in need of some refurbishment. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. Whilst service users’ rooms are homely and comfortable not all service users benefit from living in rooms that meet the requirements for space. Service users benefit from living in a clean, pleasant and hygienic home. EVIDENCE: The home is situated at the end of a cul-de-sac and is in keeping with the local community. The home is in need of internal refurbishment, as the décor is looking worn. The building does not meet with the standards required for room sizes and staff facilities. The double rooms are far too small to be used for two service users to share and consideration must be given to offering rooms as single 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 18 accommodation as soon as possible. Two of the single rooms are also very small and could be utilised better as offices or either visitors or storage rooms. Staff have tried hard to personalise these rooms with service user being involved with the choice of colours etc. One of the double rooms has an ensuite but this is not used and urgent consideration must be given to removing the broken shower cubicle and making more use of the space. The sink in this room is also broken and must be replaced. The room also needs re-decorating. Overhead tracking for hoists was seen in the lounge, 3 bedrooms and in the bathrooms. The lounge had patio doors that led to a pleasant garden, however access to the gardens from the lounge was denied to wheelchair users due to the framework of the door. Service users confined to wheelchairs had to access the garden from another route. It is advised that access from the lounge through the patio doors is provided for wheelchair users. The home has two kitchen areas and these had recently benefit from some new equipment. Two new dishwashers, a new washing machine and one new cooker had been provided, with a further new cooker on order. More fire extinguishers and fire blankets had also been provided. Some new furniture for one of the lounges had been ordered including a sideboard, a coffee table and an entertainments unit for a hi-fi and television. This lounge has had a problem with damp, which the manager stated had improved. It is advised that this be monitored to ensure it has been completely dealt with. One of the shared bedrooms had a severe problem with damp in the ceiling. The manager confirmed that this had not affected the stability of the ceiling tracking. It had recently undergone a service and the engineer had confirmed the stability. The problem with the ceiling must be dealt with as a matter of urgency. The source of the problem must be determined and addressed. The home has a specialised shower room for the benefit of the service users, which is fully adapted to meet their needs. All personal toiletries were seen to be stored in individual containers. Laundry facilities were provided in the garage. There was no separate hand washing facilities, with only one sink that was used for domestic tasks. The floor was not impermeable and the wall finishes were not readily cleanable. The room had lots of cobwebs. There was no sluicing facilities. This needs to be addressed. On the day of the inspection the homes was clean, hygienic and free from offensive odours. The homes cleaning schedule was seen and it was evident when talking to staff that it was an important part of their roles within the home and that they took responsibility for the tasks. The home is in need of a planned maintenance and renewal of fabric programme. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 The service users benefit from being cared for by staff who have a good understanding of their needs though severe staff shortages have resulted in service users not always receiving consistent care or appropriate levels of activities. EVIDENCE: Staff spoken to during the inspection demonstrated that they knew and supported the main aims of the home and were working their way through all the new policies and procedures provided by the new providers MCCH Society Ltd. All staff had job description which gave clear guidance to what was expected of them and reflected their roles. The home does not use volunteers. Staffing records were now stored at the home but as mentioned earlier in the report there was not secure office to keep then in. Theses files were stored in a locked cupboard in the service users dining room. Discussion with the staff and manager indicated that they had the relevant competencies to meet the service users needs. The manager was currently drawing up a training matrix that she stated would be available for the next inspection, however discussion with staff confirmed that they had completed many relevant training courses with MCLS, the previous provider. Thirteen members of staff had completed NVQ 2, with four more working towards the award. Three members of staff are also working towards NVQ 3. Fifteen hold 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 20 first aid certificates. The home surpasses the required 50 of staff with NVQ 2. The home is understaffed by approximately 130 hours per week and this is having a negative impact on the service provided to the service users. The manager stated that recruitment had begun and that she is now more involved with the recruitment and selection of staff. The amount of agency and bank staff is unacceptably high and it will be a requirement that more staff be recruited as a matter of urgency. The manager was working excessive care hours to assist in covering the homes care rota. This has resulted in some management responsibilities being neglected or not completed. The inspector does wish to stress that the manager is working to the best of her ability and does recognise that this is to be done in the best interests of the service users. This situation has also prevented staff from receiving regular and recorded supervision. The fact that the home does not have a private office also prevents supervision from happening. Both problems need to be addressed as a matter of urgency. Staff stated that they felt well supported, as they were mainly supervised when working alongside senior staff. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 The service users benefit from having a manager who is supported well by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. EVIDENCE: The manager is registered with the Commission and is currently completing her Registered Manager Award. On the day of the inspection it was evident that she was competent and sufficiently experienced to run the home and meet its stated purpose, aims and objectives. It was also evident that the welfare of the current service users was very important to her. Staff confirmed that the manager was approachable and communicated a clear sense of direction and leadership. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 3 3 1 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 1 3 2 x 3 2 Standard No 11 12 13 14 15 16 17 3 2 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 1 x x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1-2 Downer Court Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 23 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 YA 1&5 Regulation 4 and 5 Requirement The registered provider shall produce and make avaliable to the Commission a copy of the homes Statement of Purpose and a Service User Guide. A contract stating the terms and conditions shall also be provided The nutritional needs of the service users are to be assessed and appropriate methods of weighing service users are to be provided All service users are to be offered the option of a single room Timescale for action Action plan by August 31st 2005 2. YA 17 13 Actionplan by 31st August 2005 3. YA25 23(2)(f) 4. YA 27 23 5. YA 26 23(2)(b) 6. YA33 18(1) Actionplan by 31st August 2005 The broken shower cabinet in the Actionplan double room must be removed by 31st and the broken sink replaced August 2005 The damp and damaged ceiling To be in the bedroom must br repaire completed or replaced by August 31st 2005 The registered person shall, To be completed by having regard to the size of the care home, the statement of September purpose and ther number of 30th 2005 service users ensure that at all times suitably qualified, competant and experienced staff Version 1.30 Page 24 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc 7. YA 36 18(2) are working at the care home in such numbers as are appropriate for the health and welfare of the .service usersl The registered person shall ensure that persons working at the care home are appropriately supervised. Actionplan by 31st August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA 24.12 YA 10 and 36 YA 30.4 YA 24.9 Good Practice Recommendations it is recommended that the home has a planned maintenance and renewal of fabric programme for the fabric and decoration of the premises, with records kept it is recommended that an office is provided to ensure secure and confidential files are safely stored and for a place for private supervision be held. It is recommended that the laundry floor finishes are impermeable and the walls finishes are easily cleanable It is recommended that all areas of the home are accessible to the service users in that the doorway to the garden from the lounge is made accessible. 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent. ME16 9NT 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 1-2 Downer Court H56-H06 S64406 1-2 Downer Court V228846 050705 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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