Inspection on 02/04/07 for 101 Sutton Road

This inspection was carried out on 2nd April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

101 Sutton Road 29/09/05

101 Sutton Road 11/01/05

101 Sutton Road 10/08/04

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Insight - Eastchurch

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Seabourne House

33 St John`s Church Road

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE 101 Sutton Road Maidstone Kent ME15 9AD Lead Inspector Debbie Sullivan Key Unannounced Inspection 2nd April 2007 09.20 X10029.doc Version 1.40 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 101 Sutton Road DS0000024081.V334187.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 Older People and 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. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 101 Sutton Road Address Maidstone Kent ME15 9AD 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) 01622 671064 101sutton@mcch.org.uk MCCH Society Limited Vacant Care Home 5 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (3) of places 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. LD (E) for three service users whose dates of birth are: 20/08/1935, 28/09/1935 and 31/12/1935 29th September 2005 Date of last inspection Brief Description of the Service: 101 Sutton Road is one of a number of registered care homes managed by MCCH Society Ltd in the south east of England. The home offers 24-hour care to 5 service users who have a learning disability and are aged 50 years and over, with a strong emphasis on older persons care. The home offers accommodation on two floors with five single rooms. There is a small lounge/dining room and kitchen area, which is compact for five service users, and a large rear garden. The home has two call bells fitted and TV points in the bedrooms and lounge. The home is situated off a main road with local shops and amenities and is within easy reach of Maidstone town centre with a bus service close by. Service users are supported to attend a wide range of social, leisure and day activities that suit their ages and interests. The home has a small team of care staff, with the manager and senior support worker working together to cover a 24-hour roster. The home does not provide waking night cover but there is a sleep in staff member. The cost of the service is £918.00 per week. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection site visit of 101 Sutton road took place over five and a half hours. During the visit time was spent with the manager, senior support worker, service users and other staff members. Four service users were present; one service user was spending time at another home for a trail period due to a change in their needs. It was the new manager’s first day at the service; the previous manager had transferred within the organisation due to restructuring. The new manager had also transferred within MCCH, knew the house well and was very familiar to service users and staff The premises were toured and some records and documents were read, three service users were case tracked. The pre inspection questionnaire completed by the service provided additional information, as did comment cards and survey forms completed by service users. What the service does well: What has improved since the last inspection? The care plan process continues to be refined and person centred planning is being introduced. The ground floor bathroom refurbishments have been completed. A new lounge carpet has been fitted, there is some new furniture and the lounge/dining room has been redecorated. Some work surfaces in the kitchen have been replaced. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are able to access information about the home so that they can make an informed decision about choosing to live there. EVIDENCE: The home’s statement of purpose and service users guide provide clear and comprehensive information in written and pictorial formats, the statement of purpose will need to be updated due to recent staff changes. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 9 The home has had no new admissions for some time although due to a change in mobility needs, one service user was staying at another MCCH house for a trial period. A member of staff had transferred as well to help them settle in and ensure their needs were met. Staff spoken with at Sutton Road said that the assessment period was going well as the other service was quieter and more accessible for the service user, those at Sutton Road were visiting regularly and saw the service user at various activities. Another service user had expressed a wish to live more independently and work had begun towards assisting them to gain more independence skills. The needs of the service users were being well met and the mix of staff and service users allows for individual interests and aspirations to be pursued. Care plans contain tenancy agreements. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are well met and care plans accurately reflect individual needs and preferences. Service users are treated respectfully by staff at all times. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 11 EVIDENCE: The care plans of three case tracked service users were read, each contained information that was up to date, thorough, well maintained and had been updated and reviewed as needs changed. Reviews take place regularly and there is plenty of contact with health and social care professionals. Changes in health needs are fully recorded and are reported to health professionals when necessary. Risk assessments are completed in depth for each service user and are reviewed. Of the case tracked service users one had recently experienced some health problems in terms of an increase in seizures, clear information was available about contact and intervention from health professionals. The service user’s medication had been changed as a result and they were less responsive than normal, staff were monitoring this closely. Another service user’s behaviour had been occasionally causing some concern, again contact with health professionals in respect of this was recorded. A referral for speech and language therapy had been made and the service had identified a need for staff to receive additional training in the management of behaviours. Routine medical appointments are recorded and when a service user recently needed to spend a few days in hospital staff regularly visited, the service user commented on this and had clearly appreciated the contact having had no family to visit. Service users access the GP of their own choice. Service users contribute to care plans and their preferences as to how care is delivered are recorded, this includes gender preferences. Person centred planning continues to be introduced and the new manager intends to start this process with the service user wishing to live more independently. Throughout the inspection the interaction between service users and staff was friendly, good natured and staff were respectful, there was a comfortable family atmosphere, service users were involved in decisions such as if they wished to go out with staff and when to have a meal. Medication is safely stored and all staff administering it have been trained to do so, two medication errors had been reported to the Commission this year, procedures had been improved upon and the manager expressed their intention to review them further. MAR sheets inspected were properly completed. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported and encouraged to make choices about their daily lives and to access activities of personal choice and interest. Independence is promoted and encouraged. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 13 EVIDENCE: Staff support service users to access a wide range of activities, their ages and personal interests are individually taken into account in the planning. Each service user has a weekly plan and activities include horseriding, attending local day activities services, shopping, visiting relatives, going out for meals, aromatherapy and attending a local Salvation Army social group. During the site visit two service users were supported to attend an art group in the morning and returned keen to show off Easter cards they had made. Another went shopping locally with a member of staff and one service user helped with the household chores, as their horseriding had been cancelled due to a horse being ill. In the afternoon all four service users went to an MCCH Easter event that they were looking forward to. Staff take service users out in their own cars or on public transport and all service users have bus passes. The service user hoping to live more independently is working towards using public transport on their own. Service users spoke of holiday plans for this year, one was looking forward to a fairly local seaside holiday and another was planning to go to Blackpool, one service user preferred days out. A member of staff was discussing plans for a day out on to the coast on Good Friday weather permitting. Information on care plans and general observation during the site visit showed that service users are enabled to be as diverse as possible in their activities and interests, and staff make every effort to plan shifts so that they can be supported individually or together to access them. A service user who is unable to verbally communicate is able to make their preferences known with the aid of pictorial information placed throughout the house and a pictorial reference aid developed with them by a Speech and Language therapist, staff are also aware of the meaning of their gestures and moods. Contact and visits from friends and family are promoted; one service user spends time with a relative each weekend and contact with peers in other services is kept up. A service user spoke of visits to another MCCH house that they enjoyed. Meals are planned on a rotational basis that includes a week for each service user to decide upon meals to be provided, this is very flexible and there is always choice. Shopping is done three times a week so there is plenty of fresh produce. A service user spoken with said they liked the meals especially meat and potatoes. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable service users and their representatives to raise concerns or complaints. Service users are protected from abuse by the home’s recruitment procedures and staff awareness of adult protection issues. EVIDENCE: The home has a complaints procedure that is available in a pictorial format and is displayed in the entrance hall. No complaints had been recorded as was the case at the time of the last inspection. The ability of service users to voice complaints is varied; some would need the support of friends, families or advocates to make a formal complaint. One service user has an advocate and another has recently been referred to an advocacy service. Staff receive adult protection training and are subject to POVA and CRB checks during the recruitment process. There are no adult protection alerts open regarding the service. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a well-maintained and homely environment however the lack of an alternative communal living area compromises opportunities for privacy. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 16 EVIDENCE: The home is well decorated and furnished, clean and warm. Since the last inspection the refurbishment of the downstairs bathroom has been completed. The radiator in the bathroom was not covered; the senior support worker reported this to an MCCH housing officer during the inspection who advised it would be covered a result. There is also an upstairs toilet and bathroom, a small area of flooring in the toilet needed replacing. Some redecoration of the living areas had taken place in recent months and the lounge was bright and airy. The open plan lounge leading to the dining room is the only living area and there is no space available for private visits or conversations, or for service users to be on their own apart from in bedrooms. The bedroom occupied by the service user currently trying out another home is on the ground floor and of a good size; the organisation should give strong consideration to converting this to a communal living area if the service user does move, rather than using it as a bedroom permanently. Bedrooms are all individually decorated and service users have lots of possessions in them reflecting interests and backgrounds including photos, books, toys and TV’s. Each service user helps to clean their room with an appropriate amount of support, some new furniture has been provided and a service user mentioned they like their new bed. There is a large pleasant garden that can be accessed via a ramp with handrails; the patio is on the level. Staff maintain the garden well and it would be improved with a little additional attention. The laundry is small and situated appropriately away from food preparation or dining areas. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a confident and well trained staff team. Staff are genuinely committed to meeting the needs of the service users and enjoy their work. EVIDENCE: The manager, senior support worker and support workers staff the home during the daytime and one member of staff sleeps in at night. Enough staff were on duty to meet the needs of service users at home and to accompany them together or individually to the days activities. Permanent and bank staff were on shift, where bank staff are used they are those well known at the home. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 18 All staff were confident with the service users and there was a mixture of good natured chatting and fun, alongside clear guidance and information being given about the days activities. A service user said, “all the staff are nice to us” The senior support worker said that recruitment had just taken place for a new support worker and was planned for a temporary senior to cover maternity leave. A key working system is in place, the key worker for the service user possibly moving said how much they missed them being at the home. The majority of staff have gained an NVQ in care qualification, others are currently undertaking it. Staff recruitment files are held centrally and were inspected in January 2007 with no major shortfalls being found. Staff meetings are held bi monthly. A member of staff spoken with said that they found the staff team friendly and the organisation was supportive. MCCH has a comprehensive training programme and staff receive update training on mandatory topics and service specific training such as on epilepsy, person centred planning and Makaton. During the site visit the senior support worker was confirming training dates on a number of topics for the team. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 20 31.32,33,34,35,36,37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager is experienced, known to the service users and staff and familiar with the ethos and working practices of the home. The home is well run in the best interests of service users and staff and their health and safety is promoted. EVIDENCE: The site visit took place on the new manager’s first day, the manager was well known to the service users and staff and very experienced having been employed within MCCH for many years and having previously managed another service. The manager has gained the RMA award and NVQ level 4 in care and intends to apply to become the registered manager. The change of management had taken place due to organisational restructuring. Service users did not appear fazed by the change and had been informed of it in good time. The house was friendly and busy with quite a few comings and goings as staff and service users went to various activities; this led to a feeling of a family atmosphere and people joining together at points of the day whilst they pursued individual interests as well and had some one to one support. A sample of staff supervision files were read, supervision takes place regularly although some recording had not been signed or dated. Staff meetings are held bi monthly. Internal quality assurance systems are in place, Regulation 26 visits take place and an annual survey is circulated to service users and their families, the manager said that those for this year were due to go out. A sample of 2006 forms returned by relatives contained positive views. Service users all have an appointee within the organisation, except for one whose relative is appointee; all transactions involving service users finances are recorded and audited. Records were checked for two service users and amounts tallied with receipts. Each service user has a one to one session weekly for budgeting; a session took place during the visit. Records are stored securely and entries are appropriate and clear. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 21 Health and safety monitoring is good, fire checks and practices take place regularly and service users are instructed as to how to proceed in the event of a fire, the home has valid insurance in place. A weekly walking route to check for need for any repairs takes place and as well as individual risk assessments full house and staff risk assessments are completed relating to activities undertaken. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 ENVIRONMENT Standard No Score 19 3 20 2 21 3 22 3 23 3 24 3 25 2 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 3 33 3 34 3 35 3 36 2 37 3 38 3 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 23 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. OP20 Standard Regulation Requirement Timescale for action “The registered person shall having regard to the number 31/07/07 23(2)(a)(e)(f) and needs of service users (h)(i) ensure that the physical layout of the premises meets the needs of service users. Adequate communal accommodation is provided for service users, the size and layout of rooms occupied or used by service users are suitable for their needs, the communal space provided is suitable for the provision of social, cultural and religious activities and suitable facilities are provided for service users to meet visitors in communal accommodation, and in private accommodation separate from service users’ own rooms. In that the organisation must consider the provision of communal space where service users can receive visitors in private and use the space for personal privacy and activities. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 24 The use of any bedroom that becomes vacant must be considered for this purpose. This requirement is repeated from the previous inspection, at that time no possible room was becoming available that could be used as a communal area. 2. OP25 13 (4)(a)(c) “The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety and unnecessary risks to the health or safety of service users are identified and so far as possible eliminated.” In that the radiator in the downstairs bathroom must be fitted with a cover. 30/05/07 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. OP9 It is strongly recommended that policies and procedures for medication administration are reviewed regularly and all staff be reminded of them. The competence of all staff to administer medication must be reassessed. It is recommended that all supervision records are signed and dated by the supervisor and staff member. Refer to Standard Good Practice Recommendations 2. OP36 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 25 3. OP38 It is recommended that the small area of damaged flooring in the upstairs toilet and gaps in the skirting board be made good. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local 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. 101 Sutton Road DS0000024081.V334187.R01.S.doc Version 5.2 Page 27 - 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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