Inspection on 07/08/07 for 24 Surrenden Road

This inspection was carried out on 7th August 2007.

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

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

24 Surrenden Road 03/10/06

24 Surrenden Road 06/02/06

24 Surrenden Road 21/11/05

24 Surrenden Road 21/02/05

24 Surrenden Road 07/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 24 Surrenden Road Brighton East Sussex BN1 6PP Lead Inspector Nigel Thompson Key Unannounced Inspection 7th August 2007 09:00 24 Surrenden Road DS0000014123.V343242.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 24 Surrenden Road DS0000014123.V343242.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. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 24 Surrenden Road Address Brighton East Sussex BN1 6PP 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) 01273 504344 01273 552626 Brenda@rogate.org Hallcreed Limited Julia Brooks Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is three (3). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability only to be accommodated. Date of last inspection 3rd October 2006 Brief Description of the Service: 24 Surrenden Rd is registered with the Commission for Social Care Inspection (CSCI) to provide residential care and support for up to three people with learning disabilities. The home is situated in a pleasant residential area of Brighton, close to local parks, shops and pubs. It is convenient for bus services into the city centre and other areas, and is close to Preston Park station. The home does not provide nursing care. The building is a two-storey house with accommodation on both floors. It is not suitable for people with mobility problems. There is a garden to the rear of the property. The current service users, who have lived in the home for many years, have the use of the lounge and a large kitchen/diner and also the hydrotherapy pool located in one of the other properties owned by Hallcreed Limited. Information about the service, including the recently updated Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at 24 Surrenden Road, as of 31 July 2007, is £88.50 - £98.85 per day. Additional charges are made for hairdressing, certain activities, magazines, toiletries and holidays. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours in July 2007. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was adequate. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were three service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with the service users and the Acting Manager. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: The comfortable, relaxed and welcoming environment has evolved over many years and reflects the general stability and commitment within the staff team and the open and inclusive management style. Through working closely and consistently with residents, staff have developed awareness and a sound understanding of their individual care and support needs. Service users are encouraged and supported to make decisions about their lives. Where appropriate and practicable, they are involved and regularly consulted on many aspects of life in the home, including menu planning, activities and the choice of colour schemes for individual rooms and communal areas. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 24 Surrenden Road DS0000014123.V343242.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 24 Surrenden Road DS0000014123.V343242.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): 1, 2, 3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The thorough admission policy and procedure ensures that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: There have been no admissions to the home for over fifteen years, however it was noted that there is a clear admission policy and procedure in place. Comprehensive information is made available to all prospective service users and it was noted that the quality and accessibility of the home’s ‘Statement of Purpose ‘ and the ‘Service User Guide’ is further enhanced by effective use of illustrations. Following a referral to the home, the manager will visit the prospective service user and carry out a pre-admission needs assessment, including any personal care needs, mobility issues, social and cultural needs and family involvement. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 10 In addition to establishing whether the individual’s care and support needs can be met within the home, the manager also stressed the importance of ensuring compatibility with existing service users. For individuals referred through Care Management arrangements, the manager confirmed the need for a completed Social Care Assessment being provided. All prospective service users have the opportunity to visit the home to look around and meet with existing residents and staff before moving in. 24 Surrenden Road DS0000014123.V343242.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed service users’ care plans enable staff to meet assessed needs in a structured and consistent manner. Individual plans, including risk assessments are regularly reviewed to reflect changing support needs. Systems for consultation and participation remain effective and service users are treated with respect and encouraged and enabled to make decisions about their dayto-day living. EVIDENCE: Service users care plans that were examined showed clear evidence of annual community reviews and of interim six monthly ‘in-house’ reviews. It was noted that since the previous inspection, as recommended, details are now recorded of who attends the review meeting. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 12 It was noted that each service user’s care plan contained an impressive and informative summary of the past year, compiled by the individual resident, their key worker and the manager. A welcome development since the last inspection is that ‘Person Centred’ individual care plans are now written in the first person. Plans examined were found to include a comprehensive ‘Personal profile’ (‘Who is…….’) containing information regarding family and friends; details of the individual’s daily routine and day care arrangements; likes and dislikes and their hopes and goals for the future. As part of the reviewing process it was noted that the impressive and comprehensive ‘Individual programme plan’ is discussed, which includes sections relating to ‘Health and hygiene’, Household activities an opportunities’ and ‘social and community interaction. Goals met from the previous review are recorded, as are goals not met (with reasons why) and agreed goals for the current review. It was clear from plans that were examined that residents are directly involved in the review process and recording sheets are signed to that effect: ‘Read and agreed with ………..’. The acting manager confirmed that residents are regularly consulted regarding many aspects of their day-to-day living, including choosing colour schemes for their room and communal areas, menu planning, recreational and leisure activities and holidays. This was supported through discussions with residents, spoken with during the inspection: ‘I am looking forward to moving into a larger room soon and I have already chosen the colours that I want’. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from generally appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan, as part of the initial assessment process. It was evident that activities, including college courses, visiting garden centres and friends and shopping, reflect these interests and effectively meet service users’ individual and collective social care needs. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 14 Service users spoken with during the inspection were clearly enthusiastic about their individual day services: ‘I can’t wait for college to start in September, with the new courses I’m doing – pottery and local history’. The acting manager confirmed that visiting at the home remains unrestricted and residents are able to see their friends or relatives in the lounge or in the privacy of their own room. Where appropriate, in accordance with their wishes, links with residents’ family and friends are encouraged and supported. Menus are varied and balanced and are based on service users’ identified likes and preferences. An alternative to the main meal is always available and the ‘flexible’ four-week menu is regularly discussed with service users. The acting manager confirmed that residents are not generally involved in meal preparation. Effective communication within the home and good interaction between the service users is evident. Since the previous inspection, as recommended, regular and structured residents’ meetings have been reinstated. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their care plan, residents are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with residents in a professional and respectful manner. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 16 Documentary evidence was in place to demonstrate that the health and emotional care needs of individual residents continue to be met within the home. All residents are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. The acting manager confirmed that close and effective working relationships between residents and their key worker ensured that any subtle change in a resident’s mood or behaviour could be picked up on and addressed at an early stage. Policies and procedures, relating to the control and administration of medication, are in place and were found to be accurate, well maintained and up to date. The acting manager confirmed that staff directly involved in these procedures receive appropriate training. The home operates a ‘Monitored Dosage System’ (MDS) and regular monitoring of procedures as well as guidance and advice continues to be provided by a local pharmacist. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. An accessible and up to date complaints procedure ensures that service users, staff and visitors feel able to express any concerns. However service users are at potential risk from inadequate staff training and outdated policies and procedures relating to abuse and adult protection. EVIDENCE: Since the previous inspection, as required, a simple and accessible complaints procedure has been developed for the benefit of service users’ relatives or other visitors to the home. However it is recommended that the policy and procedure be reviewed and amended to include updated contact details for the CSCI. For the benefit of service users living in the home, a simple illustrated complaints procedure has been developed, with the use of symbols. The acting manager confirmed that due to the variable levels of mental capacity among the service users, it is unclear as to the individual awareness or understanding of the process. It was noted that no complaints have been received by the home since the previous inspection. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 18 The home has inadequate and outdated policies and procedures on adult protection and despite previous requirements there was no evidence of a ‘Whistle Blowing’ procedure having been developed. The acting manager confirmed that staff are made aware of relevant policies and procedures relating to abuse and adult protection through their induction training. She also added that all staff are to attend Adult Protection training, which focuses specifically on identifying different forms of abuse and procedures for alerting. However there is still no documentary evidence that staff receive the appropriate guidance, as relevant staff training records were not made available for inspection. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The service is accessible, generally safe and clean and remains suitable for it’s stated purpose. Service users benefit from pleasant accommodation that is comfortable, homely and welcoming, however the current state of the kitchen is unsatisfactory and certain areas throughout the home are in need of redecoration. EVIDENCE: It is evident that there has been little change in the physical environment at 24 Surrenden Road since the previous inspection and standards remain generally satisfactory throughout. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 20 The premises, including the lounge, conservatory, kitchen, dining area and large garden are accessible, safe and clearly meet their stated purpose. During my ‘guided tour’ of the premises it was evident that the reasonably well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. The acting manager confirmed that the currently neglected looking kitchen and dining area is due to be totally redecorated and refurbished in the near future, with replacement units and a new floor covering. ‘The work is planned to be carried out in September’. Many radiators throughout the building were found to be rusty and clearly showing signs of wear and tear. Following discussion with the acting manager, it is required that the overdue repainting or upgrading of the radiators be carried out. Since the last inspection, as required, personal and environmental risk assessments have been carried out, including the possible need for radiator covers. It was noted that these assessments were most recently reviewed in April this year. The acting manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. It was noted that infection control policies and procedures are in place and clearly adhered to. A daily cleaning rota is evidently in place for individual rooms, which staff are expected to sign off when the work is completed. Levels of cleanliness remain satisfactory throughout. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There is not always sufficient trained and competent staff on duty to meet the assessed needs of the service users. However, service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: Ongoing concerns remain regarding the minimal staffing levels currently operated within the home and the potential impact that this has on the care and support of service users, as well as the inevitable effect on their social and recreational opportunities. This is evidently more significant at weekends when there is no college or other day care provision and residents are often in the house for long periods of time. The acting manager confirmed that staffing levels have not improved since the previous inspection and remain clearly inadequate: 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 22 ‘It has been easier since I’ve been able to drive the house car. There is only ever one member of staff on duty at any time – except Christmas and New Year’. ‘It’s not ideal but it could be much better with another member of staff on duty, even for part of the shift, so people can go out’. A resident added: ‘Exactly. That’s true!’ As discussed, this situation continues to be unsatisfactory and evidently does not always ensure that the assessed needs of residents are being met, or that their best interests being served. It was noted in his ‘Person Centred Plan’ that one resident had commented on the need for everyone to go out together, due to there being only one member of staff on duty: ‘I can find it frustrating when someone does not want to go out’. ‘I need help to understand why I cannot go out all the time’. When residents are out at college or day centres the home is often left completely unstaffed during the day. However the acting manager described the ‘on call’ system that is in place, with staff from another home being available if needed between 9.00am and 5.00pm. Management level ‘on call’ cover is provided outside of ‘office hours’ and is detailed on the rota. Staff have suitable job descriptions and a sample of these was made available for inspection. Staff confirmed that they have contracts of employment and that they are familiar with the General Social Care Council’s code of conduct, and a copy was available in the home. A current duty rota was made available for inspection. Staff recruitment records, although not held in the home, were made available and inspected at a later date at the head office. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 23 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from a competent and experienced manager and are protected by satisfactory health and safety procedures. However their best interests are not always safeguarded by inadequate and ineffective quality monitoring systems. EVIDENCE: The ‘unit manager’ is now registered with the CSCI. She is clearly competent to run the service and has achieved NVQ level 4, in Management and Care. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 24 During the manager’s current extended leave an experienced senior carer has taken over responsibility for running the home, with full support from the Care Services Manager. The home continues to use a pictorial satisfaction feedback chart for residents to demonstrate how they are feeling about the service they receive. There was no evidence of a survey having been carried out since July last year, when responses then indicated a general level of satisfaction with the care and support provided. Following discussion with the acting manager and in view of their variable levels of communication, it is recommended that feedback from residents’ relatives and stakeholders in the community also be sought formally from time to time. Despite previous requirements and recommendations, files for policies and procedures that were examined were still found to be disorganised, poorly maintained and are evidently not being reviewed and updated regularly. The acting manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. She added that training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. Training records examined at the head office were able to support this. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 25 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 3 2 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 2 X X 3 X 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 26 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. Standard YA23 Regulation 13 (6) Requirement It is required that service users be protected from potential abuse by appropriate staff training and relevant and up to date policies and procedures. (Previous timescale of 30.11.2006 not met.) It is required that sufficient qualified and competent care staff are on duty at all times to meet the assessed needs of service users. (Previous timescale of 30.11.2006 not met.) It is required that quality monitoring systems be improved by seeking the views of service users’ relatives and other stakeholders. (Previous timescale of 31.12.2006 not met.) It is required that the premises, including the kitchen, dining area, floor covering and radiators be kept in a good state of repair and well maintained. Timescale for action 31/10/07 2. YA35 18 (1) (a) 31/10/07 3. YA39 24 (1) (3) 31/10/07 4. YA24 23 (2) 31/10/07 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 28 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 24 Surrenden Road DS0000014123.V343242.R01.S.doc Version 5.2 Page 29 - 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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