Inspection on 25/02/08 for 12 Channel Lea

This inspection was carried out on 25th February 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

12 Channel Lea 06/12/06

12 Channel Lea 12/01/06

12 Channel Lea 31/08/05

12 Channel Lea 15/03/05

12 Channel Lea 15/03/05

12 Channel Lea 15/03/05

12 Channel Lea 15/03/05

12 Channel Lea 09/12/04

12 Channel Lea 09/12/04

12 Channel Lea 09/12/04

12 Channel Lea 09/12/04

12 Channel Lea 28/02/04

12 Channel Lea 28/02/04

12 Channel Lea 28/02/04

12 Channel Lea 28/02/04

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

CARE HOME ADULTS 18-65 12 Channel Lea Walmer Deal Kent CT14 7UG Lead Inspector Michele Etherton Key Unannounced Inspection 25th February 2008 09:30 12 Channel Lea DS0000041065.V359122.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 12 Channel Lea DS0000041065.V359122.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. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 12 Channel Lea Address Walmer Deal Kent CT14 7UG 01304 242363 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) The Robinia Care Group Ltd Miss Sharon Anne Head Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2006 Brief Description of the Service: 12 Channel Lea is situated in the town of Walmer on the outskirts of Deal. The house is situated in a quiet residential street that is close to the local amenities, shops and bus service. The home is registered for three adults with learning difficulties, who may need personal care and support from staff. The home is run by Robinia care Ltd. 12 Channel Lea has a small front garden and a small back garden, both of which are well maintained by the clients in the home, there is also a garage in a block of garages. There are no car parking facilities at the home, but parking is available in the street. The home is very tastefully decorated and furnished; the clients appreciate this and show a keen interest in keeping the home looking nice. The fee for this home is approx £1,700 per week. For more details of the fee and what it includes please contact the Provider. Past reports are available from the Provider. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good, quality outcomes. An inspection of this service has been undertaken and included an appraisal of information received by CSCI about the home and from the home since the last inspection in December 2006. The Home has returned a completed AQAA that was completed to a good standard and informed us about what the service thinks they do well, areas they have identified for improvement and future planning. We undertook a site visit of this service at short notice which lasted approximately five hours, during this all key inspection standards were assessed including progress made by the service in addressing previously identified shortfalls. The site visit incorporated a tour of the premises including one bedroom with the permission of the resident concerned, and all communal areas including the garden. Samples of documentation including support plans, risk assessments, medication administration records (MARS), and staff recruitment files were examined. One person who lives in the home was available to talk with during the site visit and contributed to our understanding of what it is like to live in the home. They said they were happy there and enjoy being involved in the day-to-day routines of the house. Discussions with the manager and staff were also undertaken in addition to observations of staff supporting a resident during the site visit; information gained from this has been influential in the compilation of this report. What the service does well: People live in a pleasant, comfortable and well maintained home, it is homely and they have free access to all communal areas. They are supported and encouraged to develop their potential and attain independence. Staff’ enable and facilitate opportunities for people in the home to obtain work, and develop their skills outside of the home. People in the home are supported to maintain their interests and hobbies and explore new experiences. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 6 People in the home are supported to lead active lives and make use of specialised and mainstream community facilities. What has improved since the last inspection? What they could do better: The home need to progress and implement the support plans agreed with people in the home and a new timescale has been agreed to achieve this outstanding requirement. Some good practice recommendations have been issued, these are: A review of the present and impractical locking arrangement for the front door of the home, to ensure this is not the unwitting cause of a restriction on a resident who chooses not to have a door key. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 7 A review of arrangements for withdrawing money from personal allowances held by the home for one resident which are inconsistent with other practices for the same resident. The need to ensure that staff’ recruitment files are compliant in their content with Care Home Regulations 2001. The need to ensure staff have the necessary policy and procedure guidance to support their work with people in the home who may experience mental health issues, breakdown and subsequent admission to hospital under the Mental health Act 1983. 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. 12 Channel Lea DS0000041065.V359122.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 12 Channel Lea DS0000041065.V359122.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who come to live at the home can be confident that they will be consulted about their needs and aspirations to ensure these can be met. EVIDENCE: Discussion with the manager, staff and a review of some service users files confirmed that the people living in the home are being consulted about and participating in discussions around their current needs and aspirations through “listen to me” assessments. A comprehensive assessment tool for use with people referred to the company for placement has been developed. Discussion with someone living at the home, the manager and a staff member indicated that an existing resident will be moving out shortly to a supported living placement, people in the home have been consulted about who will come into the home to replace that person. The pace of transition is tailored to the specific needs of the individual concerned, and involves opportunities to meet the people in the home and spend time at the home and with them, and has included a reassessment of need. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that they will be consulted about their personal goals and aspirations, and are more actively involved in determining their lifestyle and making their own choices and decisions within a responsible risk strategy. EVIDENCE: Discussion with someone living in the home an observation of them during the visit confirmed that the home is encouraging of independence and responsible risk taking. The resident was particularly pleased because they had achieved a task for themselves that they have previously been dependent on staff support for, a staff member was obviously pleased with the progress made by the resident and reported this would be recorded as a goal achieved. Staff’ were observed to be supportive and encouraging but not intrusive. Discussion with the manager highlighted that the home is working with people in the home to develop plans of individual support that more accurately reflect how people 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 11 want to be supported and by whom, establish realistic goal setting and find out what they want from their lives. A resident spoken with during the site visit confirmed he is discussing with staff what he wants to achieve now and in the future. This work although progressing has not been completed and remains an outstanding requirement, an extended timescale has been issued for its completion. Observation of and discussions with the resident present and staff in the house, indicate that opportunities for choice and decision making are increasing all the time with evidence that discussions between the manager and staff are reviewing and reflecting the need for some practices and implementing changes where these are no longer felt appropriate. Risk assessments are in place these will evolve more as the culture and ethos within the house changes. The manager reported that where activities have been risk assessed and changes occur that may present additional risks these are discussed with the individual resident. There are still some areas where staff are reticent about rescinding control and the rationale for this is unsound when discussed with them, e.g. the front door locking system, a person in the home not signing for their money (see standards 23 and 24 for recommendations in these areas) 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home are supported and enabled to express their individuality, tastes and preferences, to lead the kind of lifestyle they would wish. They are supported to maintain important relationships. They take an active role in the development of menus, selection and preparation of meals, and are supported to eat healthily. EVIDENCE: During the site visit a resident was observed undertaking household tasks for themselves and confirmed their responsibility for doing their own laundry and room cleaning with staff support. People in the home are actively encouraged to greet visitors and make them welcome by offering drinks etc. Discussion with a resident indicated that the people in the home lead an active and interesting lifestyle, that is different for each of them, dependent on their 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 13 interests and commitments. One person has a work placement and will be moving on from the home shortly to a supported living house, another attends a skills centre, staff are supportive of travel training, and will also provide transport to activities where necessary. Discussion with a resident at the site visit indicated that people living in the home are supported to maintain contact with their extended families and home visits are facilitated where independent travel is not an option. Staff demonstrated an awareness of relationships residents have outside the home and their support of these. One person living in the home reported that he liked living there and compared it favourably to previous placements in larger environments that he found noisy. All current residents have been offered a front door key, and two have taken up this option. One resident has actively decided not to hold a key at this time and the manager reported that this had been recorded. All residents currently have access to the kitchen and make drinks and snacks as they wish and are encouraged to offer these to guests and visitors. A resident spoken with during the inspection confirmed that residents are actively involved in making their own breakfast and lunch, and that residents are supported by staff to cook the main meal of the evening, currently there is a tendency for the most able residents to take on the role of providing meals for other residents and perhaps consideration should be given to making sure all residents have an equal responsibility for cooking for themselves and the household. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The personal and health care needs of people living in the home are met. EVIDENCE: Discussion with a resident at the site visit confirmed that some aspects of his personal care are undertaken with staff support, he reported he is happy with the level of their input around bathing and washing in particular, and is understanding of the need for this at present. The manager and staff indicated that people in the home are mostly self-caring, staff are on hand to prompt and encourage, and are able to flexibly respond to individual needs. Discussion with staff and the manager indicated that people in the home are supported to attend routine health appointments and attend more specialist appointments e.g. Psychiatrist appointments with support. Documentation 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 15 viewed confirmed a record of appointments and health contacts for individuals is maintained. The manager reported good working relationships with health professionals who have been helpful and supportive to staff at times of crisis. Staff have received training in mental health to aid their work with those residents who also have a mental health problem, it is important that they are supported in their work by the provision of clear guidance and procedures and this has been addressed further on in the report. The manager and staff reported that only trained staff’ administer medications. All three residents are actively involved in their medication regime to a greater or lesser degree dependent on capacity under staff supervision, and consents for this are recorded on files. Medication Administration sheets (MARS) viewed at the site visit evidenced that residents who are undertaking their own medication albeit under the supervision of staff are also signing MARS when medication is taken, Some residents have been offered to have their medication stored securely in their rooms but have refused to do so for their own reasons and this decision has been respected by the staff team. The medication of people in the home is routinely reviewed and reduced, in some cases this raises concerns for staff regarding the effects of reductions and how this might impact on the quality of life experienced by individual residents, all reductions are closely monitored for effects. Medication records viewed are completed satisfactorily. PRN guidelines were noted for individual residents. Consideration should be given to the development of medication profiles to give staff and individual residents better understanding about what individuals medications are for, possible side effects and whether there is capacity for diversity in administration times so as not to impact on the lifestyle of the resident if possible, the manager was open to the idea of flexibility in offering medications in keeping with user lifestyles where this was agreed by the person prescribing and there would be no adverse effect. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home feel confident of approaching staff with their concerns; systems are in place, which protect them from harm and abuse. EVIDENCE: Discussion with a resident during the site visit established that he felt confident about speaking to staff if he was unhappy with something. The manager reported that resident meeting minutes could evidence issues raised by them that have been taken through the complaints process, also the home has actively supported a resident recently to access an advocate to ensure their views were listened to by their placing authority. The staff team has access to adult safeguarding and whistle-blowing policies and procedures and have attended training in adult safeguarding. Behaviour plans have been developed for individual residents. Staff have trained in a BILD accredited SCIP programme, and the Manager is undertaking training that will lead to a graduate diploma in Applied Behaviour. The finances of people in the home are audited closely. The home is encouraging of residents leading an independent lifestyle and this involves having money and spending this how they choose, as a consequence the home has a policy that residents who have the capacity to manage their own money 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 17 may make purchases of up to £10 at any one time without the need to provide receipts thereby promoting greater independence and personal responsibility. A review of documentation and further discussion with staff highlighted an anomaly in that one resident who is assessed as able to withdraw and sign for money from a bank account is not accorded the same rights in respect of personal allowance monies managed by the home, this appears to stem more from staff concerns regarding the acceptability of the signature used and consequently accountability issues rather than from any other concerns regarding competency, this was discussed with the manager who agreed the rationale for this is not sound and this will need to be reviewed, and this is a recommendation of this report. 12 Channel Lea DS0000041065.V359122.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): 24,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People enjoy living in a safe, comfortable and well maintained home. They are consulted about decorative changes in the home and are enabled to express their personal tastes and interests within their own space. EVIDENCE: During the site visit someone who lives at the home was happy to provide a guided tour of the premises, showing his own bedroom by choice and communal areas of the home including the garden. He confirmed that he is responsible for cleaning his room his laundry and was observed doing these activities at the beginning of the site visit. Bedrooms belonging to other people in the house were locked and no attempt was made by the resident conducting the tour to enter these rooms that were respected as being private. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 19 The Resident was happy to show his bedroom and is clearly very happy with it he commented that he had chosen the colours used for the room, he said he has everything he wants in the room and this was filled with things that interest him. He has a key to his room but has refused a key to the front door as he is always accompanied by staff when out. People living on the first floor of the home share a bathroom, this was seen to be clean and functional but would benefit from the upgrading of the bath panel, which is faded and bare of varnish in places. The downstairs bedroom has an en-suite. The house is pleasantly and comfortably furnished and maintained to a high standard of cleanliness. The gardens to the front and rear of the property are well maintained by the current residents. The front door cannot be opened from the inside unless by key, this is restrictive of anyone wishing to leave the building, answer the door or get a breathe of fresh air. In discussion with the manager and staff the rationale as to why this arrangement exists is unclear, none of those currently resident are considered to be at risk from wandering off and all have been offered a front door key. The manager and staff were open to reviewing the present arrangement and saw the merits of this as on occasion keys had been mislaid, whilst this is not a fire hazard as the door unlocks in the event of a fire, it will not do so otherwise without a key. It is recommended that the manager review the current system of locking on the front door to allow residents the right to open the front door as and when they wish and to vacate the building if necessary without recourse to a key, this is particularly relevant to residents who have chosen at this time to not hold a key but whose freedoms are restricted by the present arrangement. 12 Channel Lea DS0000041065.V359122.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): 32,33, 34,35,36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’ living in the home are supported by enough, competent and welltrained staff. They’ can be confident that appropriate checks of new staff have been undertaken to ensure their suitability, and that the quality of support, knowledge and awareness of staff is routinely monitored and appraised. EVIDENCE: Discussion with someone who lives in the home during the site visit indicated that there are usually two staff available on day time shifts the manager reported that this can increase dependent on what activity is going on, or whether a particular person in the home is in need of additional staff support as can happen from time to time. The manager and staff have considered the impact on staffing of the admission of a more dependent resident and they are prepared to respond flexibly as the need arises. 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 21 The manager reported that they do not use agency staff but do have some people on a flexi bank who they use in addition to staff overtime hours to cover vacant staff hours in the short term, this provides greater continuity and stability for the people in the home. Discussion with two staff who have commenced work in the home within the last twelve months confirmed that they have received an induction into their role and have completed induction booklets, these have now been implemented across the company and all staff employed after a specific date have been required to complete these. The staff team have achieved NVQ2 training and above. A review of a staff file evidenced that whilst necessary vetting and checks have been undertaken, there were some recording and content omissions’; the manager reported that a more comprehensive recruitment document that requires interviewers to address all relevant areas has now been implemented. It is recommended that the home ensure that staff files contain relevant documentation as stated in Regulation 19, and schedule 2 of the Care Homes Regulations 2001. The company have taken on board issues of resident involvement in recruitment and are putting together a panel of resident experts who have expressed an interest in participating in interviews, and who will be receiving specific training to help them, they will also be involved in the short-listing of prospective staff. AQAA information supplied by the home and discussion with the manager confirmed that the company has appointed a training manager who has been instrumental in ensuring that a program of mandatory and more specialised training is in place for staff, updates are routinely advised to those needing to refresh training, the training manager has been helpful in accessing relevant specialist training for staff e.g. Mental health training. Staff supervision notes were noted on a staff file, staff spoken with reported they have regular supervision and feel supported, they confirmed staff meetings are held and a sample of minutes of these viewed. 12 Channel Lea DS0000041065.V359122.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): 37,39 & 41,42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well run. Systems are in place to ensure effective monitoring is happening and people in the home have opportunities to express their views and influence change. EVIDENCE: The manager is well established within the company and is experienced in providing Learning disability services, her experiences at recent inspections have raised her awareness and she is now highly motivated to promote the independence of people in the home in every aspect of their daily lives, she talks about “the light suddenly being switched on”. She herself has undertaken 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 23 recent training courses in person centred planning and mental health and also is undertaking a Diploma at the Tizard centre in behaviour. The manager confirmed she is now in receipt of regular comprehensive supervision from the area manager. Resident meetings have been discontinued at the request of residents, this was discussed with the manager as there is some value in the residents having a forum where issues can be discussed and recorded and taken forward on their behalf and consideration should be given as to how this can be perhaps less formally re-introduced that fits in better with the preferences and lifestyle of people in the home. The manager spoke about the very comprehensive audit of services now implemented by the company, this is in addition to regulation 26 provider visits, financial audits, health and safety audits, medication audits and competency assessments. In addition people living in the have opportunities to express their’ views through questionnaires and user group forums currently being established. Outcomes’ from this feedback at local and national level is incorporated into service development plans along with areas of development highlighted by the local, regional and national management teams. The manager will need to ensure that outcomes of annual quality assurance are published and made available to the commission if requested. The manager has reported within the AQAA that all relevant policies and procedures are in place and have been reviewed and updated, it is noted that one relating to Mental Health admissions to hospital is not in place, as two of the people living at the home will have additional mental health issues and have varying experiences of breakdown, it would be good practice for the home to develop guidance and procedure for staff to work to ensure people in the home experiencing breakdown receive an effective and consistent support from staff., and this is a recommendation. The manager and staff confirmed they are kept updated of changes to policies and procedures and must sign that they have read and understood them. Staff spoken with thought they were given enough information about procedures and the people they support. The AQAA indicates that health and safety checks have been carried out within timescales. The manager confirmed the fire risk assessment has been updated. 12 Channel Lea DS0000041065.V359122.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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 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 3 X 3 X 3 X 3 3 X 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12,16 Requirement Standards 6, 7, 9, 18. Consult with service users (through person centred plans) and improve service users opportunity for independence and fulfilment. (Not met within timescale of 30/4/07 Timescale for action 25/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA23 YA24 YA34 YA41 Good Practice Recommendations Home to ensure that residents who have capacity to manage their money take ownership and responsibility for signing for withdrawals of cash from their accounts. Home manager to review the front door locking system, to ensure these arrangements are not unduly impacting on the rights and freedoms of home residents. The Home to ensure that staff files contain all relevant documentation as stated in Regulation 19 and schedule 2 of the care Homes regulations 2001. Home to develop a policy and procedure to inform and guide staff in supporting people experiencing mental DS0000041065.V359122.R01.S.doc Version 5.2 Page 26 12 Channel Lea health breakdown and admission to hospital under the Mental Health Act 1983 12 Channel Lea DS0000041065.V359122.R01.S.doc Version 5.2 Page 27 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 12 Channel Lea DS0000041065.V359122.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!