Inspection on 20/09/07 for 26a Sussex Avenue

This inspection was carried out on 20th September 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

26a Sussex Avenue 04/01/10

26a Sussex Avenue 08/11/06

26a Sussex Avenue 07/03/06

26a Sussex Avenue 14/01/05

26a Sussex Avenue 20/05/04

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 26a Sussex Avenue 26a Sussex Avenue Canterbury Kent CT1 1RT Lead Inspector Jenny McGookin Key Unannounced Inspection 20th September 2007 09:50 26a Sussex Avenue DS0000023717.V346345.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 26a Sussex Avenue DS0000023717.V346345.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. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26a Sussex Avenue Address 26a Sussex Avenue Canterbury Kent CT1 1RT 01227 768845 01227 478896 acorn@mcch.org.uk 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) MCCH Society Ltd Mrs Janet Rita Castle Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2006 Brief Description of the Service: The Home is purpose built and has some minor adaptations and alterations to meet the requirements of a residential care home catering for people with physical difficulties. The Home is currently registered to accommodate ten residents. The Home is effectively two similarly constructed units that are joined together providing residents with a wide range of facilities. There are ten bedrooms for the residents’ use arranged on one floor. All of the facilities are accessible to persons using wheelchairs. The Home is well equipped with apparatus to assist with all the residents needs. There are good communal facilities and the Home benefits from a reasonable front garden and a secluded patio area that provides residents an opportunity to pursue leisure and social activities or horticultural hobbies. The current fees for the service at the time of the visit range from £867.58 to £1,174.66 per week. Extra charges are payable for personal items such as: clothes, toiletries, magazines, leisure and social activities, extra furniture, personal T.V. music system. Also for service users’ own holiday costs. Information on the home’s services and the CSCI reports for prospective residents should be detailed in the Statement of Purpose and Resident Guide. The e-mail address for this home is acorn@mcch.co.uk 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to inform this year’s key inspection process; to review findings on the last inspection (November 2006) in respect of the day-to day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took just over seven and quarter hours, and involved meeting with two senior support workers, and three support workers. The registered manager was on annual leave. The inspection also involved a complete tour of the premises and the examination of a range of records. Two residents’ files were selected for care tracking. Conversations with the residents were limited in most cases by their level of disability, but feedback questionnaires were completed to represent three of them, and feedback was also obtained from a day care office and district nurse. Interactions between staff and the residents were observed during the day. What the service does well: What has improved since the last inspection? MCCH continues to make a timely response to requirements and regulations and key standards are met. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 6 The registered manager has made progress with the relevant care and management qualifications. There is now good evidence of Regulation 26 monthly visits by the Registered Person. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have confirmed that they were given the information needed to decide whether this home would meet their needs. Each placement is subject to terms and conditions governing the rights and responsibilities of both parties, so that service users can know what to expect, as far as they are able. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which were last assessed in 2004 and judged to be fully compliant with the elements of the National Minimum Standards. At the time of this site visit, both documents were subject to review and will, therefore, be reassessed once this process is completed. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 9 At the last inspection it was established that MCCH has a contract with the commissioning authorities, which is kept at its headquarters (i.e. not accessible to the inspection). There is also an “Assured Shared Tenancy Agreement for Supported Housing” which describes the landlord / tenant arrangements and the terms and conditions, fees and facilities governing each tenancy. This document is written in generally plain language, and has an appendix, which commits the MCCH to provide personal care, care planning / review process. Some of its provisions have been presented in a more accessible format for the residents. The last admission to this home was in 2000, but the others came into this home over the nineties – some time before the emergence of the National Minimum Standards. Consequently, their admissions were not assessed within that context. However, feedback from three service users confirmed that they feel they were consulted over their move into this home and that they had received enough information about the home before they moved in so they could decide if it was the right place for them. 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users benefit by being involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: This home’s individual service plans (hereafter referred to as ISP’s) are personcentred and are designed to enable each service user’s health, personal and social care needs to be addressed, particularly when these are comprehensively underpinned by observational charts and individualised programmes of activities. Where limitations are in place, these are justified by documented statements (e.g. furniture provision) or risk assessments. Records confirm that these plans are being reviewed regularly to respond to any changes. They focus on how the service users can develop their skills and interests, and carefully detail the extent to which staff need to support or intervene, so that they are practical working tools. Most elements of this 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 11 process are written in the first person and in an accessible format, to keep each service user’s perspective central. There continues to be active support from the service users’’ relatives and each service user has a key worker, to build up special relationships with them and work on a one to one basis. Staff showed a sound understanding of the importance of service users being supported to take control of their own daily lives, and to make their own decisions and choices. See section on “Lifestyle” for details on emerging outcomes for service users, most notably possible employment prospects for one service user, and recreation initiatives for others. This is judged very promising. The service users already have communication passports to help staff interpret their nonverbal responses. But the home’s plan is to refine staff interpretative skills to empower service users even further. It is a mark of this home’s understanding of the scope that person centred care planning has for changing people’s lives and the investments it is making, as much as these early outcomes, that the overall score for this section has, therefore, been raised from “good” to “excellent”. The last inspection established that the home has also made arrangements to access local advocacy services, should this be required, to ensure the service users’ rights remain central to the operation of this home. In practice their intervention has not been required. The home’s arrangements for keeping confidential information secure against unauthorized access are judged satisfactory. . 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Services users benefit by the support they get to make choices about their life style, and to develop their life skills. Social, educational, cultural and recreational activities have succeeded in raising individual’s expectations EVIDENCE: The format of this home’s ISPs is designed to address each service user’s scope for personal development, community presence and fulfilment in terms of relationships and activities. The extent to which they are supported to exercise choice and control over this, is detailed in the section “Individual Needs and Choices” above. The home ensures that there are service users group meetings to gather information about their level of interest in planned activities. One service user said, “I can mostly do what I want. Sometimes as I have 9 other house mates I will share my support with them”. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 13 Recreational activities on site include watching TV, videos, music, and access to the home’s garden and sensory room facilities. Service users are supported to carry out some light domestic chores, like helping to tidy their rooms or carrying laundry or crockery. They are also able to access the kitchen facilities, subject to risk assessment. Recreational activities off site include bowling, swimming, meals out, shopping, theatre, discos i.e. activities not necessarily identifiable with or restricted to the service users’ disabilities. MCCH has disbanded its own Visiting Person Team (which was used to support community access) but the home has benefited by the extra staffing hours this has made available to it. Staff are confident that service users are still able to access the full range of community resources VPT supported them with. Of particular interest was the work being done to access carriage riding for those service users who are wheelchair bound, so that they could obtain some of the same experiences as those able to enjoy horse riding. The home has also been pursuing opportunities for adapted sailing events. One member of staff said, “the people there do it all voluntarily and really take their time”. The home still relies on outside agencies such as the DOS day centre [Day Opportunities Service], Strode Park, PHAB [Physically Handicapped and Able Bodied], Gateway Club and MCCH’s own equivalent, Echoes club and there are events like the Saturn disco in Ashford. MCCH provides each of the service users with a week’s holiday each year (organised by Phab). Feedback from one day care officer indicates good relations are maintained by the home with this resource and with the service users. The day care officer said the home “responds well to request or service users’ requests. All staff have good communication with the service users and staff at DOS. Staff have good open relationship with service users, which I observed from the day centre. Service users are always happy to see staff when they come to collect after a day at Day Centre”. Since the last inspection, work has been done to explore one service user’s employment potential – working alongside the management team at the MCCH head office. This is judged very promising. Another service user has been supported to access adult training classes at Canterbury High School. And there was anecdotal information on one service user’s involvement in the recruitment and selection of staff. There are open visiting arrangements, and records confirm the active involvement of relatives in the care planning processes. Service users have access to two cordless phones, each of which is fitted with a speaker. And one resident has a telephone answer-phone in his bedroom. One service user said, “Staff support me to visit my nan’s most Sundays”. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 14 Each individual’s nutritional needs and preferences are established as part of the care planning processes and carefully monitored and amended on a dayto-day basis thereon. The menus are planned in advance but applied flexibly. The service users use some adapted cutlery and crockery to enable them to feed as independently as possible. During the site visit, three service users and staff were joined for lunch in the Oaks Unit, and the meal was judged well prepared and presented. One service users’ choices were established with subtle hand movements, while another was more able to verbalise. In each case the rapport was appropriately familiar and respectful. 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that service users receive is based on an assessment of their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The ISP processes properly assess the extent to which each service user requires assistance with their own personal care. Records and observed practice confirmed that the service users’ choice and control are actively promoted by staff as far as possible. There is a good range of personal aids and equipment readily available, and records confirm these are well maintained to support both service users and staff. All the bedrooms are single occupancy and there are enough toilet and personal care facilities to guarantee their availability and privacy. Staff are available on a 24-hour basis to assist service users. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 16 The ISP process routinely addresses a range of standard healthcare needs e.g. GP (there are three practices involved), community nurses, chiropodist / podiatrist etc. Records have been set up on file to document access to a range of other healthcare professionals as appropriate. Feedback from one visiting district nurse confirmed that the home had been “very co-operative with providing health care needs for their clients… They provide thorough care for their clients, providing excellent health and social care. They do their utmost for their clients and liaise well with the district nursing team”. The lack of regular input from a suitably qualified physiotherapist was raised for attention at the last inspection and found to be outstanding, and continues to be judged a significant shortfall, given the residents’ level of disabilities. As one member of staff put it: it is one thing to try to implement passive exercises demonstrated by a physiotherapist (though this carries its own risks, without training or supervision). Quite another to assess its benefits. But it is accepted that the MCCH had been lobbying for this at a regional level. Staff also identified the lack of access to a hydrotherapy pool as in need of attention, although there was anecdotal information about the home’s attempts to secure provision. The medication arrangements in the Oaks Unit were assessed against the National Minimum Standards and found to be compliant. There is a dedicated storage cabinet for each unit, properly secured against unauthorised access. Medication administration records seen showed no anomalies or gaps and the home keeps medication reference material in each unit. Staff said they had received training, and that this was subject to regular updates – and this was confirmed by certification seen on file. 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to express their concerns. There is a complaints procedure in an accessible format available to service users. Service users are protected from abuse, and have their rights protected. EVIDENCE: MCCH has policies on complaints and adult protection, which have been judged satisfactory by a previous inspection (March 2006), and there is also a pictureassisted version of the complaints procedure to make it more accessible to service users. There is a checklist in each service user’s file for staff to sign and date as confirmation of their having explained the complaints procedure to them but the ones seen on this occasion were both dated 2001, and should be more regularly updated to raise awareness. Feedback obtained on this occasion from three service users confirmed that they knew who to tell if they were unhappy. “I can speak to my mum (sometimes on the phone). I can speak to my support workers who I have known a long time”. Less clear was their awareness of the formal complaints procedure, however. The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 18 records can evaluate the extent to which their responses are listened to and acted on. It is accepted that the home has plans to refine staff interpretative skills. There is currently no active input from independent advocacy services, though arrangements for access are reported to have been put in place. In meetings with the inspector, staff confirmed their commitment to challenge and report any instances of abuse, should they occur. 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home is judged safe, well-maintained and comfortable. The environment enables service users’ independence. EVIDENCE: This site visit confirmed findings from the last site visit in November 2006. The home’s location (in terms of access to Canterbury) and layout are generally suitable for its registered purpose, and measures are in place to keep the premises secure against unauthorised access or egress. There had been one incident of vandalism since the last inspection, which was judged effectively reported and managed. All areas of the home were inspected and found to be homely, comfortable and clean. Comfortable temperatures and lighting levels were being maintained. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 20 Since the last inspection mixing valves have been installed on all taps likely to be accessed by residents, to keep them safe. The grounds are reasonably flat throughout and landscaped to provide pleasant outlooks from the bedrooms. The home has a “No Smoking” policy. The communal areas of this home are spacious. The communal furniture tends to be domestic in style and there were homely touches throughout. All the bedroom windows offer pleasant views of the gardens. The seating in the dining and lounge areas are uniform in style, but this is appropriate, given almost all the residents tend in practice to use their own comfy-wheelchairs. The two unit kitchens are both light, airy, clean and well maintained. Each unit has a separate communal bathroom/WC, shower room/WC and WC i.e. reasonably accessible to bedrooms and communal areas. All the bedrooms are single occupancy, and judged well maintained and personalised. With two exceptions, all the beds are discreet high-low models to keep manual handling safe. In terms of the other bedroom furniture and fittings, the bedrooms were, however, generally not fully compliant with all the provisions of the National Minimum Standards. Their non-provision was justified in each case (usually in terms of the need for space for wheelchair or hoists) by generic statements on each file. All the maintenance records seen were up to date and systematically arranged. Since the last inspection (November 2006), purpose designed clinical waste pedal bins have been introduced into each unit’s laundry. This is judged good infection control. Only two matters were raised for attention – specifically, the need to fireproof bedroom doors; and the need to minimise the obstruction posed by scaffolding. 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The following staffing arrangements apply: • • The morning shift from 7.30am till 3.00pm; and the afternoon shift is from 2.30pm till 10.00pm. In each case there should be one senior support workers and five support workers. The night shift is from 9.30pm till 7.30am. There is one waking night staff, who will have been on duty from 2.00pm till 10.30pm. And there is a second member of night duty staff, who is asleep but on call (and who will then normally be on duty till 2.00pm). There is a cook who works from 11.am till 6.00pm from Tuesday to Friday. • 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 22 There are no other ancillary staff, though MCCH has its own maintenance department - support workers are responsible for cleaning the home and also have some grounds maintenance tasks. They are to be commended on the level of cleanliness found. This staffing arrangement was judged sufficient to meet the assessed needs of the residents. Staff individually confirmed feedback obtained at the last site visit – that they share a commitment to work flexibly to maintain safe staffing levels at busy times of the day and to meet the changing needs of the residents. Recruitment records were not assessed on this occasion as the MCCH has a centralized system for managing its personnel records, based at their Head Office at Maidstone. An agreement was reached between the Director of Operations MCCH, and the Commission in September 2002, that staff personnel records could be supplied in advance of announced inspections, and then returned to the MCCH head office. There is also an undertaking to meet any individual requests from inspectors to supply information and records. This was in this instance not judged warranted, given that staff have individually consistently confirmed a robust recruitment process to comply with all the key elements of the standard. Feedback also confirmed that a service user has been actively involved in the recruitment and selection process, in line with best practice standards, and that prospective staff are invited to visit the home and service users, so that their confidence can be established. Staff confirmed that they had supervision sessions, usually 6-8 weeks (i.e. in excess of the National Minimum Standard), and that these sessions covered all those elements prescribed by the standard. Staff training records were inspected on this occasion, which confirmed information obtained from staff and previous inspections i.e. that there is a satisfactory level of investment. 16/24 staff are reported to be accredited to NVQ Level 2 or above, with two more in prospect. Three staff are also NVQ Assessors 26a Sussex Avenue DS0000023717.V346345.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager, Mrs Castle, was not on duty on the day of this inspection, but subsequently reported having completed her Registered Managers Award and is working with an MCCH assessor on her NVQ Level 4 accreditation. She is hoping to complete this by December 2007, and is also scheduled to start a management development course in January 2008 – all of which is judged promising. 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 24 The structure of the overall organisation offers generally clear lines of accountability; and the MCCH is now demonstrating a better level of compliance with its regulatory responsibility to carry out its own inspection visits at least once a month. MCCH has a corporate business plan for each year and each unit is then tasked with setting up its own “Team Charter” to implement corporate objectives on a local level. In each case the unit’s team has to identify key personnel, performance measures and indicators of success. At the time of this site visit this process was scheduled for a half-term review. The processes for managing this home are judged open and transparent, and the delegation of responsibilities is appropriate. All the policies prescribed by the Commission are reported to be in place and subject to systematic review by MCCH, to ensure they are in line with best practice standards. Systems are in place to monitor staff adherence to policies and procedures during their practice, and feedback obtained by the Commission indicates the home is regarded highly by other professionals. There was good evidence of service users being supported to make choices on a day-to-day basis, and a strong person-centred approach to their care. Less clear, however, was evidence of a formal quality assurance initiative, other than that led by the Commission, to obtain full compliance with this standard. The views of service users and other stakeholders will always be crucial to the success of this. Records confirmed a satisfactory level of investment in staff training, and this is underpinned by regular health and safety audits. The home appeared to be generally very well maintained and hazard free. All maintenance records seen were up to date and systematically stored. 26a Sussex Avenue DS0000023717.V346345.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 X 2 X 3 3 4 X 5 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 4 34 X 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 2 3 3 3 X 26a Sussex Avenue DS0000023717.V346345.R01.S.doc Version 5.2 Page 26 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 YA37 Regulation 10 Requirement The Registered Manager needs to attain the qualifications specified in standard 37. Original Timeframe 28/04/06; 31/12/06 Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA22 Good Practice Recommendations Service users would benefit by access to regular physiotherapist input and to hydrotherapy. The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. Building. The following matters are raised for attention: • The need to fireproof bedroom doors; • The need to minimise the obstruction posed by scaffolding. There should be effective quality assurance processes in place to measure the home’s success in meeting its stated aims and objectives. Feedback fr0om stakeholders will be DS0000023717.V346345.R01.S.doc Version 5.2 Page 27 3 YA24 4 YA39 26a Sussex Avenue crucial to the success of this. 26a Sussex Avenue DS0000023717.V346345.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 Text phone: 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 26a Sussex Avenue DS0000023717.V346345.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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