Inspection on 03/07/08 for 123 Calmore Road

This inspection was carried out on 3rd July 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

123 Calmore Road 03/07/06

123 Calmore Road 10/01/06

123 Calmore Road 16/05/05

123 Calmore Road 08/12/04

123 Calmore Road 13/07/04

123 Calmore Road 09/03/04

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Dalewood Respite Care

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REACH Upton Court Road

Fairways

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Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 123 Calmore Road Totton Southampton Hampshire SO40 2RA Lead Inspector Chris Johnson Unannounced Inspection 3rd July 2008 11:00 123 Calmore Road DS0000012374.V366922.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 123 Calmore Road DS0000012374.V366922.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. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 123 Calmore Road Address Totton Southampton Hampshire SO40 2RA 023 8066 8139 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) www.new-support.org.uk Dimension (NSO) Ltd Mrs Linda Julia Ann Turner Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 3rd July 2006 Brief Description of the Service: 123 Calmore Road is registered to provide care and accommodation for six adults with learning disabilities. The home is arranged in two bungalows, with access between them via an office. Staff work in both bungalows, but service users are encouraged to live separately. The service is provided by Dimension (NSO) Ltd and the building is owned and maintained by Swaythling Housing Association. The home has three cars and there is a local bus stop directly outside the home. The current fees are £1358.70 - £1363.96 per week. Fees do not include hairdressing costs, chiropody, toiletries, basic costs of holidays and use of the house car. 123 Calmore Road DS0000012374.V366922.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 Star. This means the people who use this service experience good quality outcomes. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards, compliance with regulations, previous requirements and to assess what the outcomes are for people who live at his home. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out over one day on 3rd July 2008 whereby we looked at all key standards. Previously to this, we carried out an annual service review of the home on 15th January 2008 and this did not raise any issues of concern. All regulatory activity since the last inspection was reviewed and taken into account including any notifications sent to the Commission for Social Care. The manager completed an Annual Quality Assurance Assessment (AQAA) prior to the annual service review. Surveys were sent to five people living at the home, fourteen members of staff and four health professionals. At the time of writing this report we had received completed surveys from two people living at the home and five members of staff. We also took into consideration responses from relatives to surveys completed in January 2008 as part of the annual service review. During this visit we looked at the physical environment including, people’s bedrooms and all communal areas of the home. Staff and care records were inspected. Some members of staff were spoken with and others were observed during their day-to-day interactions with those living at the home. We examined records, policies and procedures. Due to communication difficulties and the complex needs of the people living at the home the inspector was not able to hold discussions with them. However the inspector was able to talk to people briefly, interact with them and spend time observing the care being given to them. The manager was present throughout the visit to answer questions and discuss issues. Verbal feedback was provided at the end of the inspection. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Improvements also need to be made to the system of recording recruitment practices to fully demonstrate that a thorough process is followed. The home needs to ensure that standards of care planning and risk assessments are applied to everyone living at the home. As there are some inconsistencies in this. Some parts of the garden would benefit from being maintained and made more useable. Currently maintenance of the garden is reliant on staff having the time and skills to maintain it. It may be more practical to employ a gardener. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 7 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. 123 Calmore Road DS0000012374.V366922.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 123 Calmore Road DS0000012374.V366922.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, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are assessed prior to admission so that the individual and the home can be sure that the home is right for them and will meet the person’s needs. EVIDENCE: Previously to this inspection there had not been any new admissions to the home for a number of years. The last inspection of the home did not raise any concerns with this outcome area. During this visit we asked to look at pre admission assessments and care notes for the one person who had moved into the home since our last inspection. The manager had not kept her initial assessment notes neither had the home received a care management assessment. We discussed the assessment process with the manager. The manager explained that the person had visited several times prior to moving in. We saw documented evidence of these visits and this included records of what the person did during the visits and how they interacted with other people living at the home and the staff team. We saw that as part of the moving in process their relatives had visited as had staff from the persons’ previous home. The manager explained that this had enabled them to determine whether they could meet the persons’ needs. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 10 The manager had obtained all relevant written information from the persons’ previous care home and also said that she had his need with other professionals before any visits had been undertaken. We were not able to discuss the moving in process with people living at the home. However we did discuss these with staff who commented that although the process had seemed quite quick they had sufficient accessible information before the person moved in they said that this proved helpful and that the person fitted into the home well and that in their opinion it was an appropriate placement. The home still had one vacancy at the time of this visit however in discussion the manager explained that they would not fill this vacancy unless they were sure that any potential resident was fully compatible with the rest of the household. It was agreed with the manager that in future assessment documentation would be maintained and that written care management assessments would be obtained. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessments are generally of well maintained. However there were some inconsistencies with this. This means that the standard of recorded information is not the same for everyone and therefore care and support needs may get overlooked. People are supported to make choices and decisions about their lives. EVIDENCE: The care plans of two people were looked at during this visit to the home. There was a difference in the amount of information and level of detail between the two care plans. The first care plan had been reviewed recently and contained a personal profile of the person that introduced the reader to the person. This was especially important, as the person would be unable to express this verbally. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 12 This care plan offered guidance for staff for when the person may become anxious or exhibit challenging behaviour and described what approaches to use and how to offer reassurance including key terms to use. Overall the first care plan looked at was pictorial and therefore in a format more suitable to the persons’ needs, person centred and provided staff with guidelines to support the person throughout the day and night. Areas of concern had been risk assessed and plans were in place to reduce risks. We saw from examination of the daily records that care was being provided as per the plan. The second care plan looked at was less detailed and provided less information and related to someone who had moved into the home more recently. The manager explained that they were gradually putting together more information for this person as they got to know more about them. There were guidelines in place for assisting them with their personal care needs and handwritten guidelines detailing the person’s preferred daily routine and daytime support needs. The home had also compiled an introduction to the person entitled ‘Who am I’ and this had been written in conjunction with the persons’ family. What was lacking was risk assessments and risk management plans that were pertinent to the persons’ new setting. The home had copies of risk assessments from the persons’ previous residential care home. These were however incomplete and it was unclear whether the information was still relevant. This will need to be addressed. We saw that work was being undertaken to improve on the amount of information that was in a format suitable to peoples’ needs. For instance the home was in the process of putting together pictorial boards for several of the people describing their care and support needs. The results of staff surveys were that two staff members responded that they were ‘always’ given up to date information about the needs of the people that they supported, two responded ‘sometimes’ and one responded ‘never’. Staff spoken with during the visit were able to demonstrate that they were aware of peoples’ support needs and said that they had access to care plans and all written information. Staff also told us that they communicate with each other by means of a verbal handover at the end of each shift and by keeping a written record in each person’s’ daily log of any significant issues. Relative surveys completed in January 2008 told us that their relative’s needs were being met and that people were receiving the care and support that had been agreed and or expected. Evidence seen within care plans and daily records demonstrated that people were supported to make choices and take risks as part of their everyday lifestyle. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 13 At the last inspection of the home a requirement was made that, ‘Fire evacuation risk assessments must be undertaken of all service users and shared with staff. These should be kept under review’. We saw that this had now been addressed. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home can receive visitors as often as they please and keep in touch with their family and friends. People are supported to make their own decisions and choices and they receive a healthy diet. EVIDENCE: Daily diaries are maintained for each person individually. These provided evidence that people have the opportunity to take part in a range of leisure, and social activities as well as the opportunity to learn and improve on daily living and other skills as appropriate. Information recorded in care plans and their diaries demonstrated that people could exercise choice over whether or not to engage in an activity and how to spend their time and that their right to do so is respected by staff. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 15 Feedback from surveys completed by people living at the home was that home they were free to do what they wanted to throughout the day. Relative surveys completed in January 2008 told us that people are supported to keep in touch with their families, that peoples’ relatives are kept up to date with important issues affecting them and that the home supported people to live the way they chose. Observations made during the visit would support this. Evidence was seen that people are offered a balanced menu. Meals can be chosen based on individual likes and healthcare needs. One staff member has been delegated the role of supporting people to plan the menus. We saw that pictures of different meals and foods had been developed to assist people in making this choice. A pictorial menu has been developed and this was on display on the day of the visit so that people could see what was on the menu for that day. Records are maintained of who has eaten what and written guidance was in place describing the routines and support that people required with eating meals. People have the opportunity to go shopping with staff and do so regularly providing them with the opportunity to take part in choosing food items. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are fully supported with their healthcare needs and have access to a range of specialist healthcare support. People receive personal support in the way they prefer and according to their needs. EVIDENCE: The healthcare records for two people were examined during our visit to the home. Records demonstrated that the home liaises with outside professionals and other agencies as appropriate and that people had access to a range of healthcare services such as GP’s, opticians, dentists and specialist healthcare teams. We saw evidence that peoples’ healthcare support needs are monitored and that people are supported to attend appointments as necessary. The medication administration records were checked for two people during the visit and these balanced with stock held at the home. From examination of these records it was evident that staff were following correct administration recording procedures. The home has a written medication policy and clear procedures. Evidence was seen to demonstrate that staff undergo training before being able to administer any medication and that this is regularly 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 17 updated every six months and requires staff to undertake a written evaluation and an observation of their practice. It was unclear whether the homes’ medication storage facilities met with the legal requirements for the storage of controlled drugs. The home should request formal confirmation from the supplier. If it does not meet the requirements the home must replace the cabinet with one that does conform. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory systems are in place for people to address any concerns or complaints that they may have and to protect them from abuse. EVIDENCE: No complaints regarding the home have been reported to the Commission for Social Care Inspection since the last inspection. Information in the AQAA told us that the home had not received any complaints in the last twelve months. Examination of the homes’ complaints log showed that any concerns or complaints are recorded and provided evidence that appropriate action is taken. Compliments also recorded and several were held on file from family members thanking the home for the support they had provided to their relatives. Surveys returned from staff told us that they were aware of the complaints procedure and that they know what to do in the event of anyone reporting concerns about the home. This was supported through discussion with staff during the visit to the home. It was not possible to ascertain from the people who live at the home their understanding of the complaints procedure. Of the two people who returned a survey one responded that they knew how to make a complaint and the other said they did not. The home had a pictorial complaints procedure on display. It is however advised that the manager revisits this topic with people on regular basis. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 19 Relative surveys completed in January 2008 told us that two of the three respondents knew how to make a complaint and one said that they could not remember. Two of the three said that the home ‘always’ responded to any concerns appropriately and one said ‘usually’. The home has the facility to looks after peoples’ money and to support them with their finances. We looked at the procedures for looking after peoples’ money and checked the records for two people. All transactions had been recorded and receipted as per the homes’ policy with regular checks carried out by staff and the manager. Following our last inspection of the home a requirement was made that staff must undertake alternative restraint training. In discussion with staff and the manager we were told that the homes’ policy was that they did not use restraint techniques. Staff had however received training since the last inspection in breakaway techniques. In discussion with staff they said that they felt they would benefit from training in this area that was more specific to the behaviours and needs of those living at the home. We saw that the home was aware of this and the manager was due to undertake a ‘training needs analysis’ of each staff member in order that a staff training programme could be formulated. Staff spoken with demonstrated their awareness of protection of vulnerable adults and the homes’ whistle blowing policy and procedure. All staff had undertaken in recent months the organisations’ ‘Our Approach’ training and this had covered both protection of vulnerable adults and dealing with challenging behaviour. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well furnished, comfortable and homely. The home is clean and tidy and good standards of hygiene are maintained throughout the home. EVIDENCE: During the visit to the home we saw all communal areas and a selection of bedrooms. Peoples’ bedrooms reflected their individual tastes and needs and people were observed to access and spend time in their rooms as they chose. The home was clean and tidy throughout. The general upkeep of the building is maintained and the furnishings and décor are replaced as necessary. The AQAA identified the improvements that had been made since our last visit, such as the installation of a shower room, the redecoration of both lounges and new flooring in the hallway. The AQAA also stated that the home had replaced furniture and curtains and identified further plans for improvement such as 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 21 more hygienic flooring in individual rooms and the redecoration of both bathrooms. The AQAA told us that people living at the home had been involved in the choosing of furnishings and décor. The home is arranged in two bungalows, with access between them via an office. Staff work in both bungalows, but people are encouraged to live separately. This is due to the different needs of those living at the home and this is reflected in the difference between the décor and furnishings in the two different bungalows in so much as they have been adapted to meet the different needs of the people living there. The home provides two separate garden areas on for each bungalow. In addition to this there is a large garden area largely unused and which was quite overgrown. It was reported that people did not use this part of the garden and it was sectioned off from the rest. This area would greatly benefit from being maintained and made useable. It was also noted that patio slabs were in the process of being laid outside one doorway, these were uneven in places. The manager was aware of this and undertook to have them made safe. The home does not have a gardener and the upkeep of the garden is maintained by care staff. We saw that they had been trying to improve the garden such as providing one person with a dedicated area for their own use directly from their room and the construction of a rock garden. This is however reliant on staff having the time and skills to complete these projects and it may be more practical to employ a gardener. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 22 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 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive training and are employed in sufficient numbers appropriate to the needs of those living at the home. Staff are clear of their responsibilities and receive support to carry out their role. Improvements need to be made to the system of recording recruitment practices to fully demonstrate that a thorough process is followed. EVIDENCE: During the visit to the home staff rotas were examined. These confirmed the rota to be a true reflection of actual staffing levels. Rotas are planned in advance and it was seen that they had been planned for the following weeks to come. On arrival at the home there was one senior support worker and another support worker at the home supporting three people. Two other support staff were on duty and had gone out with one person and another person was at 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 23 day services. The results of staff surveys and feedback from staff during the visit were that there were usually sufficient staff to meet the needs of the people at the home. We reported at the previous inspection that there were sufficient staff to meet the needs of those living at the home and the findings of this inspection are that this continues to be the case. From examination of staff files, discussion with staff and feedback from surveys it was evident that the home provides training and development opportunities relevant to their work. The AQAA told us that six of the thirteen permanent staff have obtained an NVQ level 2 or above and that a further six members of staff were working towards the qualification. Staff told us that they had the opportunity to undertake all mandatory training as well as more specific training. Both members of staff had attended the organisations’ ‘Our Approach’ training and reported that this had been beneficial. All members of staff spoken with were aware of their responsibilities and duties. The manager had delegated particular areas of responsibility to individual staff members such as; care planning and risk assessments, family liaison, fire prevention, housekeeping, residents’ meetings, health and safety and menu planning. People reported that this was proving successful. We looked at the recruitment records for one member of staff this being the only person to be recruited since our last visit. Not all records were available in the home. There was neither a record of a Criminal Records Bureau or Protection of Vulnerable Adults check having been undertaken. Dimension (NSO) Ltd has an agreement with the Commission for Social Care Inspection that staff records will be held at their head office. However as part of this agreement they are required to hold evidence within the home that certain checks have been completed including the dates of when these were obtained. This will need to be addressed and a requirement has been made. In all other respects recruitment records were available to demonstrate that staff are recruited appropriately and that references and checks are undertaken before offering them a post. This is consistent with findings at previous inspections. Staff told us that they felt that they received sufficient support to carry out their role. We saw records to demonstrate that people receive individual one to one supervision meetings with the manager. Staff told us that the manager was approachable and that they could discuss issues with her as and when they occurred and we saw documented evidence to support this. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 24 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The manager is accessible to staff and those living at the home. The home is well maintained and equipment is serviced to keep everyone safe. EVIDENCE: The manager has overseen improvements since our last inspection as discussed throughout this report. Requirements from the previous inspection have been addressed satisfactorily. The AQAA did not provide us with details or evidence that policies are kept under review. We looked at a selection of corporate policies and procedures held at the home and saw that some of these had not been updated for some 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 25 time. However we were told that the organisation was in the process of reviewing and updating these and they were being published on the organisations intranet to which the manager had access. We were satisfied that this is being attended to. We saw evidence that the manager held regular staff meetings whereby different policies and procedures were discussed. The AQAA gave details and evidence that maintenance checks, tests and servicing of equipment are carried out regularly. Evidence seen during the visit substantiated this. Examination of the fire logbook confirmed that weekly fire alarm checks are undertaken. We saw recorded evidence that regular fire drills take place and that fire safety is regularly discussed at staff meetings. The home has developed a quick grab file for use in emergencies and this includes pictures and descriptions of the people living at the home, plans of the house and spare keys. This was seen as good practice. The manager explained that she intended to include more details such as peoples’ medication support needs. The home has systems in place to monitor the quality of service that it provides. A representative of the organisation regularly undertakes visits to the home and reports of these visits were available for examination. From these we saw that during these visits the views of those living at the home are listened to, records are checked and the safety and upkeep of the environment is monitored. Also any shortcomings with the service are identified and plans are put in place to rectify these. Due to the communication needs of those living at the home the manager said that she was unable to hold formal resident meetings. However she had held themed nights such as aromatherapy taster sessions, DVD nights, pizza making sessions and a party and used these as a forum to gather peoples’ views. The organisation sends out surveys to staff, people living at the home and their relatives to ask their opinion of the service. This inspection did not raise or identify any concerns with regard to safety within the home environment. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 26 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 2 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 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 X 3 X 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 27 No 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 YA9 Regulation 13 (2) (c) Requirement Timescale for action 03/09/08 2 YA20 13 (2) 3 YA34 19 Schedule 2 Risk assessments and associated risk management plans must be put in place for everyone living at the home. These need to be current and be relevant to people while living at 123 Calmore Road. 03/10/08 The manager must ascertain whether the medication cabinet meets with the legal requirements for the storage of controlled drugs. Controlled Drugs, including Temazepam, must be stored in a Controlled Drugs cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Recruitment records must be 03/09/08 held at the home for all staff to include evidence that Criminal Records Bureau and Protection of Vulnerable Adults checks have been undertaken. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations It is recommended that home employ a gardener. 123 Calmore Road DS0000012374.V366922.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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