Inspection on 08/11/06 for 26a Sussex Avenue

This inspection was carried out on 8th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 4 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 20/09/07

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 8th November 2006 10:00 26a Sussex Avenue DS0000023717.V312503.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.V312503.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.V312503.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 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 Limited Mrs Janet Rita Castle Care Home 10 Category(ies) of Learning disability (10) registration, with number of places 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 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 are £1,074.66 per week. 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.V312503.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 (March 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 nine and a quarter hours, and involved meeting with the visiting service manager; three senior support workers, a member of the Visiting Persons Team, the cook / trainer and a student nurse on a week’s placement. 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 interactions between staff and the residents were observed during the day. What the service does well: What has improved since the last inspection? There has been a timely response to requirements and regulations and key standards are met. The home has benefitted by being carpetted throughout and there are new hoists in place. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 26a Sussex Avenue DS0000023717.V312503.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.V312503.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 2. The key standard was not assessed as all the admission predate the emergence of the National Minimum Standards. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 5. Each placement is subject to terms and conditions governing the rights and responsibilities of both parties. EVIDENCE: MCCH has a contract with the commissioning agencies, 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 the inspector judged largely compliant with the standard insofar as it 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 this document has an appendix, which was designed to obtain further compliance with this standard (e.g. re committing the MCCH to provide personal care, care planning / review process). There was good evidence of attempts to present some of its provisions in a more accessible format for the residents. It is accepted that the current residents would have special communication needs, which need to be catered for. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 6. The care planning processes cover a wide range of health and personal care needs, as well as social care needs. 7. Observed interactions between staff and the resident were respectful during this inspection. 8. The current residents have a number of opportunities to influence their daily routines, and their level of involvement is a matter of personal choice. 9. There are risk assessments to cover the residents as individuals, their activities and their environment (inside and outside the home), to maximise their capacity to be independent. 10. The arrangements for the storage and disclosure of confidential information are generally satisfactory. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 10 EVIDENCE: The inspector selected two residents’ care plans and reviews for closer examination and judged their formats enabled all aspects of the health, personal and social care needs of the resident to be addressed, particularly when read in conjunction with the home’s own contributory reports (written in each case by the resident’s key worker), risk assessments, observational charts and individualised programmes of activities. Review documents routinely revisit objectives set at the previous review, and checklists ensure further review dates are set and are timely. There is active support from the residents’ relatives and, as stated above, each resident has a key worker. The home has also made arrangements to access local advocacy services, should this be required, to ensure the residents’ rights remain central to the operation of this home. In practice their intervention has not been required. Records and feedback from staff confirm that the residents are supported to carry out some light domestic chores, like helping to tidy their rooms or carrying laundry, as well as to enjoy more recreational activities – all of which is likely to carry some inherent risk. The inspector found good evidence of risk assessments governing a range of activities (on and off site) in respect of the two residents selected for case tracking, and this covers key areas such as their ability to manage a door key and finances as well as the pre-emptive management of behaviours likely to place them or others at risk. Residents were observed being supported to make their own daily living decisions and accessing all communal parts of the home freely. The inspector was generally satisfied with the home’s arrangements for keeping confidential information secure against unauthorized access. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 11, 16. Residents have opportunities to learn and use some practical life skills. And the daily routines promote choice and independence, subject to risk assessments 12, 13, 14. Residents have access to a good range of activities on and off site - and this includes a mix of specialist and mainstream activities, not restricted or readily identifiable with their disabilities. 15. Families and friends are welcomed, and their involvement in the care planning processes is encouraged, subject to the residents’ wishes 17. Residents are offered a choice of suitable menus to suit their individual dietary needs and preferences, and are supported to choose and prepare or serve meals. Residents can choose where and when to eat. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 12 EVIDENCE: Employment and college training may not be realistic prospects for these residents, given their level of learning disability. The residents show some understanding of the spoken word but have very limited communication skills. Staff use a range of skills to interpret their responses and behaviours. But records indicated that the home’s staff offer direct support in some light practical daily living skills (e.g. tidying, collecting laundry or crockery, shopping) as well with recreational activities such as watching TV, videos, music, physiotherapy exercises, as well as access to the home’s own sensory room. And MCCH provides each of the residents with a week’s holiday each year. The inspector was told about one holiday to Amsterdam and an activity holiday. The home also relies on outside agencies and its own Visiting Persons Team for other activities. Examples of other agencies include the DOS day centre [Day Opportunities Service], Strode Park, PHAB [Physically Handicapped and Able Bodied], and there are events like the Neptune disco, and live music / events organised by SkillNet The inspector met with on the Visiting Persons Team during this site visit and heard how programmes of activities were applied flexibly, and how key objects had been used as cues to establish what one of the residents wanted to do on a day-to- day basis. There was also good anecdotal evidence of progress being made with one resident’s confidence to use a swimming pool and gym. The home is within reasonable access to Canterbury city centre, which means residents can access all the community resources and events that implies i.e. there is good scope for activities not restricted to the residents’ disabilities. There are open visiting arrangements, and records confirm the active involvement of relatives in the care planning processes. Residents have access to two cordless phones, one of which is fitted with a speaker. And one resident has a telephone answer-phone in his bedroom. The format of the care planning processes properly addresses the residents’ religious and cultural needs, but none of the residents was said to have shown any active interest in religious services, so this element was not further assessed on this occasion. 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 two weeks in advance and applied flexibly. The home uses spoons, straws and beakers as well as some 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 13 adapted cutlery and crockery to enable the residents to feed as independently as possible. Where food needs to be pureed, each element is pureed and presented separately, so that residents get the full benefit of their individual taste, texture and smell. Staff eat with the residents and eat the same food, which is judged a good quality assurance tool. During the site visit, the inspector joined the residents and staff for lunch in The Willows Unit, and judged the meal well prepared and presented. The pace of the meal was unhurried and the atmosphere was relaxed and congenial. Residents have a choice over where they eat, and can snack between meals. They are not discouraged from joining the cook in the preparation of meals, subject to risk assessment. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 18. Residents have choice and control over most aspects of the personal and healthcare they receive, and the environment provides facilities for privacy. 19. The home ensures that the healthcare needs of residents are properly addressed. 20. The home’s arrangements for the acquisition, storage and administration of medication are judged generally compliant with good practice standards, but none of the residents is judged able to self medicate. EVIDENCE: The care planning processes assess the extent to which each resident requires assistance with their own personal care, and their choice and control is actively promoted by staff as far as possible. 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 residents. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 15 The care planning 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. However, the lack of regular input from a suitably qualified physiotherapist has been judged a significant shortfall, given the residents’ level of disabilities. The inspector was assured that MCCH had been actively lobbying on a regional level, and that arrangements had been secured to obtain some input within the next week. The effectiveness of this will, therefore, be subject to further assessment at the next site visit. The medication arrangements were assessed against the National Minimum Standards and found to be compliant. The medication administration records showed no anomalies or gaps and the inspector was advised that the home keeps medication reference material in each unit. Staff confirmed they had received training. The home is advised to keep a copy of the Royal Pharmaceutical Guidance and British National Formulary to underpin knowledge and practice. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 22. The staff are attentive to the views and concerns of the residents, and a lot of work has been put into making the MCCH complaints policy more accessible to their special communication needs 23. There is a robust policy for responding to suspicions or evidence of abuse, and staff showed a commitment to challenge and report any instances, should they occur EVIDENCE: MCCH has policies on complaints and adult, which have been judged satisfactory by the last inspection (March 2006), and feedback obtained on that occasion confirmed that residents and relatives knew who to tell if they were dissatisfied about anything and that residents felt safe. The inspector noted that there was also a picture-assisted version of the complaints procedure to make it more accessible to residents, and there was a checklist for staff to sign and date as confirmation of their having explained the complaints procedure to the residents. The inspector was advised that there have been no complaints registered since the last inspection. The absence of recorded complaints is not, however, judged a realistic reflection of day-to-day life, given the special needs and interactions of the residents. The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 17 anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. There is currently no active input from independent advocacy services, though the inspector understands arrangements for access are 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.V312503.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 24, 25, 28. The standard of the property is good. The furniture is domestic in style, and comfortable. Residents have a choice of communal areas, and there are homely touches throughout. 26. Residents’ bedrooms are well maintained and personalised, and where they don’t have all the furniture or fittings prescribed by the National Standards this is justified – though this needs to be documented as risk assessments 27. Each bedroom has a wash hand basin, and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. 29. The home is fully wheelchair accessible and has ample useable floor space throughout. There are good garden facilities. 30. The home is well maintained, clean and free of offensive odours. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 19 EVIDENCE: 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. An overnight incident of vandalism was judged effectively managed. All areas of the home were inspected and found to be homely, comfortable and clean. Comfortable temperatures and lighting levels were being maintained. New carpets had been laid throughout the home since the last inspection. The furniture tends to be domestic in style and there were homely touches throughout. 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. All the bedroom windows offer pleasant views of the gardens. The seating in the dining and lounge areas has been replaced over the last year and are uniform in style, but this is appropriate, given almost all the residents tend in practice to use their own comfy-wheelchairs. The kitchen is light, airy, clean and well maintained. No matters were raised for attention. Each unit has a separate communal bathroom/WC, shower room/WC and WC i.e. reasonably accessible to bedrooms and communal areas. No matters were raised for attention. All the bedrooms are single occupancy. All the bedrooms were inspected and judged well maintained and personalised. In terms of their furniture and fittings, they were, however, generally not fully compliant with all the provisions of the National Minimum Standards. While their non-provision was justified, this needs to be supported by fully documented consultation and risk assessment. Only one matter was raised for attention – the installation of thermostatic mixing valves in all taps likely to be accessed by residents. All the maintenance records seen were up to date and systematically arranged. Since the last inspection (March 2006), cupboards have been installed to store incontinence pads more discreetly, and better provision had been made for the storage of substances hazardous to health (both were matters raised for attention) 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. 32. The registered person has ensured that staff have the competencies to meet the residents’ needs, and that there is compliance with the National Minimum Standard in respect of the percentage of staff with NVQ 2 accreditation, or above. 33. The home has an effective staff team, with sufficient numbers and complementary skills to support residents’ assessed needs. 34. The registered person operates a thorough recruitment procedure. 35. The registered person ensures there is a staff training and development programme. 36. Staff receive the support and supervision they need to carry out their job. EVIDENCE: The inspector understands the following staffing arrangements apply: 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 21 • • • 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 Monday to Friday. 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. The inspector was, however, unable to judge compliance with the staffing arrangements as described on an on-going basis, as staffing rotas were not included in the pre-inspection documentation as required. But staff individually confirmed a commitment to work flexibly to maintain safe staffing levels. Recruitment records could not be 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 individually confirmed a robust recruitment process to comply with all the key elements of the standard. 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: specifically, the translation of the home’s philosophy and aims into work with individuals; monitoring or work with individual residents; support and professional guidance; and the identification of training and development needs. 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. Something like 50 of staff are reported to be accredited to NVQ Level 2 or above (matter raised for attention at the last inspection). 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42, 43 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. 37. The registered manager has the relevant experience to run the home, but has yet to obtain the relevant care and management qualifications. This continues to be judged a major shortfall. 38. The management approach is open, positive and inclusive. 39. A modest start has been made to introduce quality assurance and quality monitoring systems to measure the home’s effectiveness. 41, 43. Records required by regulation for the protection of residents and for the effective running of the home are properly maintained, but the absence of some Regulation 26 monthly visits by the Registered Person is judged a major shortfall. 42. The registered manager ensures as far as is reasonably practicable the health, safety and welfare of residents and staff. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager was not on duty on the day of this inspection, and personnel records were not available. But on the basis of anecdotal information supplied, the inspector judged the manager’s experience and management style were generally appropriate to her role; and that some progress had been made to obtain the relevant care and management qualifications – though the failure to achieve the requisite qualifications by their due date must continue to be judged a major shortfall. The inspector also judged that the structure of the overall organisation offered generally clear lines of accountability. However, MCCH will need to demonstrate a better level of compliance with its regulatory responsibility to carry out its own inspection visits at least once a month – there were several gaps in the records seen and breach of this regulation is listed as an offence. This is a mixed gender team, which reports working harmoniously and flexibly to meet the needs of the residents. The residents all require support with their personal care, and the deployment of staff is organised to meet their needs and preferences (e.g. same gender care). The inspector judged the processes for managing this home open and transparent, and judged the delegation of responsibilities appropriate. There was good evidence of residents being supported to make choices on a day-to-day basis, and there was also evidence of a recent mailshot to obtain feedback from relevant stakeholders, though there had only been a modest return on this at the time of this inspection visit, so it was judged too soon to evaluate its effectiveness as a quality assurance tool. However, there needs to be a unit-specific business plan, linked to quality assurance initiatives and corporate business planning and auditing arrangements, to obtain full compliance with this standard. The views of service users and other stakeholders will be crucial to the success of this. See standard 22 on complaints. The challenge will be to demonstrate, through proper record keeping, that issues causing dissatisfaction are listened to and acted upon. Records confirmed that 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 were up to date and systematically stored. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 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 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 3 2 X 1 3 X 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23(5) Requirement Thermostatic mixing valves must be installed in all taps likely to be accessed by residents. Action plan to be submitted. Timescale for action 31/12/06 2 YA26 16(2)(c) The non-provision of bedroom 31/12/06 furniture and fittings prescribed by the National Minimum Standard must be justified in each case by documented by risk assessments and/or consultation. The registered provider shall give written notice to the Commission of the measures that will be taken to ensure that the Registered Manager attains the qualifications specified in standard 37 and the anticipated completion date of training to do so. Original Timeframe 28/04/06 The MCCH needs to demonstrate compliance with its regulatory duty to carry out visits to the home at least once a month and to male written reports of these visits in accordance with Regulation 4 DS0000023717.V312503.R01.S.doc 3 YA37 10 31/12/06 4 YA43 26 30/11/06 26a Sussex Avenue Version 5.2 Page 26 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 YA22 Good Practice Recommendations 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. 26a Sussex Avenue DS0000023717.V312503.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 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.V312503.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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