Inspection on 04/03/08 for 3-5 St Matthews Road

This inspection was carried out on 4th March 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

3-5 St Matthews Road 03/05/06

3-5 St Matthews Road 05/10/05

3-5 St Matthews Road 20/04/05

3-5 St Matthews Road 07/09/04

3-5 St Matthews Road 05/04/04

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

CARE HOME ADULTS 18-65 3-5 St Matthews Road St Leonards on Sea East Sussex TN38 0TN Lead Inspector Caroline Johnson Unannounced Inspection 4 March 2008 09:35 th 3-5 St Matthews Road DS0000028056.V357963.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 3-5 St Matthews Road DS0000028056.V357963.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. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3-5 St Matthews Road Address St Leonards on Sea East Sussex TN38 0TN 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) 01424 445924 Sussex Autistic Community Trust (Care Services) Limited Monique Laurens Care Home 9 Category(ies) of Learning disability (0) registration, with number of places 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 9. Date of last inspection 3rd May 2006 Brief Description of the Service: 3-5 St Matthews Road is registered to accommodate nine adults with an autistic spectrum disorder. The home is one of four homes in East Sussex run by the Sussex Autistic Community Trust. The registered premises consist of two semi-detached houses arranged into three separate units. House no.3 has one unit accommodating five residents whilst house No.5 has two units, one for one resident and the second for three residents. Each unit is staffed separately, whilst a manager oversees the whole service. The home is situated a short walk from the Silverhill area of St Leonards on Sea, where there are local amenities and shops. Bus services run close to the home. The home makes CSCI reports available to prospective residents and their relatives/representatives upon request. The gross weekly fee inclusive of income support is £1,200 to £2,083 as at March 2008. Residents pay for their own toiletries, hairdressing and magazines. In addition they pay half of their disability living allowance towards transport costs. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We have assessed that people who use this service receive an excellent quality of care. For the purpose of this report the people living at 3-5 St Matthews Road will be referred to as ‘residents’. As part of the inspection process a site visit was carried out on 04/03/08 and it lasted a full day. The registered manager facilitated the inspection. Over the course of the inspection there was an opportunity to meet with three of the residents. In addition time was spent with two staff members. All communal areas of the two houses were seen but only one bedroom. A wide range of records was examined including a detailed examination of two care plans and a part examination of another. In addition records seen included; staff recruitment and training, medication, complaints, health and safety, quality assurance and leisure activities. Prior to the inspection surveys were sent to the home for them to distribute to residents. Eight surveys were returned. Overall the responses provided by residents were positive but very few written comments were made. Eight residents stated that they would know who to contact if they were unhappy about anything but three residents said they would not know how to make a complaint. This was discussed with the manager who said that she thought this might have been the wording of the question rather than not understanding the process. She outlined the various opportunities that residents are given over the course of each week where they are encouraged to share any concerns or complaints they might have. One resident stated that they ‘would like to be more independent and to have a flat with staff on hand if I need it’. Since the last inspection the then registered manager has left his position as manager and a new manager has been appointed and registered. What the service does well: Care plans contained detailed advice and information about the needs of the residents and how they are to be met. Staff receive regular opportunities to attend training updates and to attend more specialist training to enable them to carry out their role within the home. Staff receive regular supervision and they stated that they feel ‘supported by the manager’. The home is continuing to use the teacch method as a way of aiding communication and to ensure that residents know what they are doing and when. A resident spoken with stated that he enjoys his work placement and all the other activities that he participates in. 3-5 St Matthews Road DS0000028056.V357963.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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3-5 St Matthews Road DS0000028056.V357963.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 3-5 St Matthews Road DS0000028056.V357963.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): 1,3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can feel confident that the home ensures that they are able to meet their needs prior to making a decision about providing them with accommodation. EVIDENCE: There is a detailed statement of purpose in place. The service user guide was being revised at the time of inspection. In the care plans seen it was evident that the religious and cultural needs of the residents had been assessed. Only one resident was admitted since the last inspection. The pre admission assessment was not seen on this occasion but the care plan was examined. This showed a very thorough assessment had been carried out by the home in all areas and there was very detailed information in place for staff to follow to ensure that the individual’s needs are met. The home are trying to secure additional funding to meet the updated assessed needs of one of the residents and a meeting has been arranged to discuss this. 3-5 St Matthews Road DS0000028056.V357963.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care of residents is enhanced because care plans contain very detailed advice of how individual needs should be met. Residents are encouraged to make choices and decisions about how they want to live their lives and record keeping that demonstrates this is now in place. EVIDENCE: Two care plans were examined in detail and another partly examined. A detailed assessment was carried out and there was detailed information provided about each resident’s ability to communicate and how best to support them. There are also a range of training plans, activity guidelines and routines in place. Each resident has development goals in place and each goal is 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 10 broken down into easily achievable steps. Information is provided about what level of support residents require to achieve each step. Risk assessments have been drawn up in relation to each task completed and these have been reviewed at regular intervals. At the time of the last inspection a requirement was made in relation to one resident to carry out risk assessments in relation to newly introduced activities. Record keeping showed that detailed risk assessments had been carried out. The manager confirmed that physical intervention is rarely if ever used. The majority of staff have completed studio three training. If it was considered that if someone was likely to require any kind of restraint this would be discussed at a multi-disciplinary meeting and staff would need to receive appropriate training to carry out the agreed intervention. Each resident has a Keyworker who meets with them on a monthly basis to discuss their goals, aspirations or any worries or concerns they might have. There are guidelines in place that staff must follow as part of this process. The type of intervention used is assessed on an individual basis. The home is working towards each resident having a signed copy of the goals that they have agreed to work towards in their own bedroom. The home also uses a token economy system to encourage appropriate behaviour. For some of the residents this involves having a sticker chart in their bedroom and whenever they behave in a particular way or achieve a particular target they are given a sticker. Once they have achieved a stated number of stickers they receive a reward (previously agreed with them) for their efforts. The type of positive intervention used is assessed on an individual basis. The teacch system is also used to assist residents in understanding what is happening on a daily basis and in what order. For some residents this will involve a pictorial view of their day for others it is sufficient to provide written details of the events. Residents understand the system and where appropriate they are involved in removing the symbols once an activity has been undertaken. The system can also be used to break down each activity into easy steps. For example when asking a resident to clean their bedroom, the steps of what needs to be done to complete this task would be written down or pictures of each task provided depending on the needs of the resident. A residents meeting is held in each house on a weekly basis and detailed minutes are kept of the outcome. During these meetings discussion is had about activities, menus, concerns, appointments, staff changes and house issues. Residents take it in turn to choose activities. Choices are documented and evidence of thorough planning in advance of meetings is also in place. From the minutes the choices and decisions made by residents can be seen within their timetables and within the daily tracker sheets. Extensive work has 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 11 been carried out to show cross-referencing of work and to ensure that both staff and residents know what needs to be done at any given time. Timetables are in place showing responsibilities regarding kitchen duties, cleaning and cooking rotas. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to participate in interesting and stimulating activities that are centred on meeting their individual needs and aspirations. EVIDENCE: New timetables are on display showing that all residents are taking part in a variety of interesting and stimulating activities. Staff advised that the increased structure to the activity programme means that residents are participating in a much wider range of activities than before. However, there is also flexibility and choice so that if someone does not want to participate or wants to do something different the home will do their best to accommodate. Each resident has free time during the week but a list of activities that residents might like to do during this time is supplied. This is to encourage 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 13 residents to think about how they would like to spend this time. If they choose to do nothing during this time this is acceptable. One resident spoken with stated that he enjoys his work placement and all the other activities that he participates in. Others spoken with also said that they enjoy their activities. Activities include bowling, swimming, cinema, pub trips, meals out, walking, One resident who used to have a very limited activity timetable has increased the range of activities they attend and this is proving very successful. A lot of thought has had to go into creating new ideas and activities that will interest and stimulate this individual. Staff are continuing to work hard to extend the range of activities without putting too much pressure on the resident. The majority of the residents were out and about at various activities during the day of inspection. Six of the residents went to the cinema on the evening of the inspection. One resident choose not to speak with the inspector but he was observed to be happy and content in his surroundings. A staff member spoken with stated that they phone the relatives of one of the residents on a weekly basis to keep them fully involved in their son’s care. Another staff member stated that they keep in touch with a relative of a resident by letters and emails. There is an eight-week set rota, which has been drawn up by the residents. The rota seen was varied and well balanced. At the residents meetings, held weekly, the menu for the following week is discussed and residents are asked to advise if they do not like what is on the menu. Changes are made to the rota at this meeting but equally on a daily basis if residents choose an alternative this is generally accommodated. Records are now kept of the actual meals served. One resident decides on a daily basis if they would like to cook their own meal or if they would like to eat from the set menu. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care of residents is enhanced because there are very good arrangements in place to ensure that their healthcare needs are met. EVIDENCE: Since the last inspection there is a new procedure in place for the holding of the key to the medication cupboard. One person is responsible for the key and any handover of key is recorded in the daily record chart. Residents require varying degrees of support with medicine management. Some self-medicate, some part self-medicate and some require full support. Some of the residents have medicine cabinets in their own rooms. Risk assessments have been carried out to determine the safety implications and they clearly detail the support required to be given to each resident. There is a folder in use that details the medication prescribed, what it has been prescribed for and any known side effects. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 15 Records seen in relation to medication administered were in order. The manager advised that they do not use homely remedies. An ‘ok-health check’ has been completed in relation to each resident. Discussion was held about the use of health action plans and the manager advised that she would look into this further. All staff receive formal training on the administration of medication. The home are introducing an in-house assessment that all staff will be expected to complete before they will be deemed competent to administer medication in the home. In addition this assessment will need to be carried out every six months thereafter. Staff reported that they are working on assisting one resident to accept that it is ok for people to have differing views on subjects for example religion and that it is not always possible to have a right or a wrong answer on a subject. Staff observed in the course of their duties were seen to be courteous and to treat residents with respect. They provided regular and consistent emotional support to two residents at regular intervals throughout the day of inspection and it was noted that there were clear guidelines in care plans regarding the need for this type of support. It was reported that all the residents are registered with the local health team either with the learning disability service or with the mental health team. When necessary appointments are made with psychologists or psychiatrists. An aroma-therapist visits the home regularly. Regular appointments are also arranged for residents to receive chiropody and everyone attends dental and opticians appointments on a regular basis. The manager advised that she will extend further the assessment of residents’ wishes in the event of dying and death and where possible the wishes of relatives in relation to this assessment will be included. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The welfare and safety of residents is promoted because the home has good systems in place to ensure that all complaints and any suspicion or allegation of abuse is dealt with appropriately. EVIDENCE: There have been no complaints recorded since the last inspection. Three of the residents advised in their surveys that they would not know how to complain. This was discussed with the manager who advised that this could have been more a problem of understanding the wording of the question. Systems in place ensure that residents are asked weekly at the residents’ meeting if they have any concerns or complaints. There is also a complaints/suggestions box at the entrance of each house. The service user guide, which was being updated at the time of inspection, also includes information about how to complain. Two adult protection alerts were made since the last inspection. In both cases the home were asked to investigate the issues and they took appropriate action to resolve them. All staff have attended or are booked to attend a training course on the protection of vulnerable adults. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 17 All of the residents pay half of their Disability Living allowance to the Trust as their contribution towards the running of the house car. The manager advised that relatives and/or representatives on their behalf have been advised of the changes in the management of this allowance. The manager advised that the Trust would be leasing another two cars for use by the home. The arrangements for supporting residents with the management of personal allowances have also changed. All of the residents’ entitlements are paid to the Trust and the Trust then takes the monies they are due. Any remainder is then paid into individual resident’s bank accounts. Residents take out an agreed weekly amount, which is divided up into daily amounts to assist residents in budgeting for their needs and activities. There is also a social and recreational budget, which pays for some activities and a meal out once a week. In addition there is a separate holiday budget to ensure that each resident who chooses to has the opportunity to go on an annual holiday. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recent redecoration means that residents live in a well-maintained and homely environment. EVIDENCE: A tour of all communal areas was carried out but only one bedroom area was seen. Since the last inspection a number of areas have been redecorated. The flooring in the dining rooms in both houses has been replaced. Carpets in all communal area in both homes have been replaced along with new curtains, pictures and fixtures and fittings. New appliances have been fitted in all areas. New televisions and sofas have also been purchased. Both of the one-person flats have also been redecorated. In one flat the carpet was replaced but 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 19 proved to be an inappropriate colour so this will be changed again in the near future. In one area of the building what was originally a separate bathroom and toilet has now become a new larger bathroom. There is a notice board showing ‘what’s on’ and residents are encouraged to look at this board to read about activities in the local vicinity. In the dining room in both houses there is now a computer for residents’ use. It was reported that residents’ bedrooms would be redecorated within the next twelve months. All area of the home seen during the inspection were clean. As a result of the fire risk assessment every fire door has been re-proofed and all the extinguishers have been replaced. Records were seen showing that a fire drill as carried out in February 2008 and that alarms, lights and door guards are tested regularly. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are good training opportunities and regular staff supervision and this ensures that staff remain equipped to meet the needs of the residents accommodated. EVIDENCE: The staff-training matrix provided showed that there are fifteen permanent staff employed although some of these staff are employed on a part-time basis. In addition there are five relief staff. Seven care staff have completed NVQ at either level two or three and some of these seven have completed both level two and three. In addition two staff (including one relief staff) are currently studying for level three. In relation to staff recruitment, two staff files were seen. One file contained all required information. In relation to the second file it was reported that the majority of the documentation is still at the head office and would be copied over to the house file in due course. The manager confirmed that she had 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 21 read through the contents of the staff file prior to the new member of staff commencing in post. It was reported that where possible the home seeks professional references, however, if there is a problem such as an applicant only ever having worker for one employer then a character reference is then obtained. All new staff complete a six-month probationary period. Initially they have a one-day house induction and this is followed up at the head office by a twoday induction course. Within the six months a modular course is then followed which involves completion of an induction booklet and attendance at mandatory training courses. The training matrix supplied showed that all staff have either attended or are booked to attend mandatory training. In addition to this a number of staff have attended courses in studio lll, autism focus, teacch and person centred planning. Staff spoken with stated that they receive regular supervision and that they feel ‘supported in the home’. A relief staff member said that they ‘feel part of the team’ and are ‘fully involved’ in the home. A staff member advised that staff meetings are held regularly and everyone is kept fully informed of any changes in care practices. 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a well run home. The improvements made to the systems and procedures ensure that staff are given a clear sense of direction and the home is continually reviewing and improving upon the way they operate. EVIDENCE: Since the last inspection the registered manager resigned from his position. A new manager was appointed and she has since been registered as manager of the home. The new manager has completed NVQ level three and is currently 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 23 studying for the Registered Manager’s Award. She advised that she has attended the provider’s training on AQAA and Klora. The manager advised that she receives monthly supervision. She also attends a manager’s meeting once a month. All senior staff took part in a meeting recently to review work carried out in the past year and to plan ahead for the next year. From this the annual development plan has been drawn up. This included maintenance issues, plans for residents and for staff. It was reported that satisfaction questionnaires were distributed recently to residents to seek their views on the quality of the care they receive. The findings are currently being assessed at head office and the results will be forwarded to the home in due course. The manager advised that three different formats were used but it is her intention to make this even more person centred. As part of quality assurance, partnership days are held twice a year. This is where the residents invite their relatives to a social gathering in their home. Generally one is held at Christmas and one is a barbeque in the summer months. In December a satisfaction questionnaire was sent to the relatives of the residents. Detailed feedback was given to those who participated on the findings and the action taken as a result. The manager advised that as part of quality assurance she spot checks record keeping in areas such as care planning and minutes of meetings. Any shortfalls are discussed in supervision with staff and if necessary further training is arranged. The manager advised of her intention to turn these spot checks into formal audits of the system in use. Prior to the inspection surveys were sent to the home for them to distribute to residents. Eight surveys were returned. Overall the responses provided by residents were positive and very few written comments were made. Eight residents stated that they would know who to contact if they were unhappy about anything but three residents said they would not know how to make a complaint. As stated previously this was discussed with the manager who said that she thought this might have been the wording of the question. She outlined the various opportunities that residents are given over the course of each week where they are encouraged to share any concerns or complaints they might have. One resident stated that they ‘would like to be more independent and to have a flat with staff on hand if I need it’. Since the last inspection all the policies and procedures have been reviewed and a number of new policies were drawn up. At the time of this inspection it was reported that they are now being reviewed again. Regulation 26 meetings are carried out each month by another manager from within the company. The person carrying out the visit alternates every three 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 24 months. Dates were supplied of a range of tests carried out in relation to health and safety. Two new boilers have been fitted since the last inspection. At the time of the last inspection the manager had advised that environmental health had not visited for several years. The home contacted the department as required and it was confirmed that they had in fact visited and the home is not due for a visit for some time. Advice was sought in relation to health and safety and the home are expecting a visit in relation to Safer Food Better Business. A thermostatic control has been fitted to an outlet that was previously not controlled. It was noted that there was an incident that affected the wellbeing of a resident that had not been reported to the Commission. This was considered an oversight. The home had dealt with the situation appropriately and at the time of writing the draft report full details of the incident had been received. 3-5 St Matthews Road DS0000028056.V357963.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 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 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 4 4 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 3 3 3 3 X X 3 3 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA21 YA37 Good Practice Recommendations The home should expand their assessment of wishes in relation to dying and death. The manager should continue to train to NVQ level 4 or its equivalent in management. The home’s quality assurance system should be expanded to formalise some of the visual audits (spot checks) that are currently carried out. 3. YA39 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South East Region The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 3-5 St Matthews Road DS0000028056.V357963.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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