Inspection on 04/07/05 for 3 Lenham Road

This inspection was carried out on 4th July 2005.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Lenham Road 29/05/08

3 Lenham Road 31/10/06

3 Lenham Road 29/11/05

3 Lenham Road 15/03/05

3 Lenham Road 10/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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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 Lenham Road 3 Lenham Road Headcorn Ashford Kent TN27 9TU Lead Inspector Lynnette Gajjar Announced 4 July 2005 10:00 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 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 Stationary 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 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 3 Lenham Road Address 3 Lenham Road Headcorn Ashford Kent TN27 9TU 01622 891067 Telephone number Fax number Email 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 Vacant CRH Care Home 3 Category(ies) of LD Learning disability registration, with number of places 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/03/2005 Brief Description of the Service: 3 Lenham Road is one of a group of small care homes managed by MCCH Society Ltd. The home provides care for three adults aged 18 –65 years with a Learning Disability. It is a 10-minute walk from Headcorn village centre and very close to a local store. The Accommodation is provided on two floors, with the three bedrooms occupied by service users on the first floor. All three bedrooms are single rooms. The three Service Users share a first floor bathroom and toilet facilities. The staff sleep-in room is located on the ground floor adjacent to the entrance hall. The ground floor also has a toilet and has had an adapted shower facility installed, dining room, kitchen and lounge. The staff roster allows for one member of staff on a sleep in duty at night. The home has no staff employed to undertake catering and domestic duties, and the homes usual routine is for all staff and service users to undertake these duties. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the announced inspection, the first in the year running from April 1st 2005 to March 31st 2006. The visit lasted from 9:30 am until 15:50 pm. The home currently has two service users in residence who have lived together for over 14 years. The home is currently running with one vacancy. The visit was spent talking directly with service users privately and collectively with the three care staff and acting manager. A service user had chosen not to leave their room for the duration of this visit but willingly accepted the inspector visiting them there. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of the service users in the report. Some judgements about quality of life and choices were taken from direct conversation with service users and observation followed by discussion with care staff and evidencing records held at the home. Time was spent reviewing care plans and other associated documentation. A tour of the premises was undertaken. Additional evidence was gained from the returned pre inspection questionnaire and comment cards received from relatives and visiting professionals. What the service does well: 3 Lenham Road provides a welcoming, homely clean, bright and airy environment. Personal health care needs are well supported. Service users are encouraged to maintain regular contact with external agencies and professionals to managed their health care and personal preferences. Service users are supported to maintain regular activities and social events at a pace comfortable to them. The home has recently benefited from a more stable staff team. Staff know the individuals well and communicate effectively with them. Excellent relationships and contact is maintained with service users and their family. A comment returned through feedback questionnaires states “We are happy with (name of service user) care standards and the quality of carers.” 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Service users personal bedrooms would be greatly improved by the removal of carpet and lining of the vacant bedroom due to the strong odour and deep cleaning taking place prior to any prospective service user visiting the home. Through the refurbishment and repair to the first floor bathroom, service users would be guaranteed a safe and comfortable bathing facility. Staff would feel more confident in the support they provide for service users through specialist input and guidance in the effective management of current behaviours being experienced. Service users and families would benefit from an easy to follow clear service user guide detailing what exactly the home is and is not able to support them with. The development of more structured, formal monitoring and auditing systems for care plans would improve service users safety and minimise the risk more effectively. The finalising the post of permanent manager will offer the service users and staff team greater stability and security. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5, Information is available to enable individuals to make an informed choice about living at 3 Lenham Road. EVIDENCE: Both service users have lived at the home for a number of years. However since the departure of a fellow resident last year, the current group living relationships have become more tense due to changing dynamics of those living here. There are no plans for anyone to imminently ‘move on’. This is an area staff and the manager should explore further through service user reviews due to the lack of interaction observed and evident. The organisation does have policies / procedures in the event of a new admission including sharing of information from other persons involved in the care of a new service user. A service user sat with the inspector to look through the new statement of purpose, understanding some of the information held and confirming their understanding by saying. “Not half” in response to the inspector’s questions or remaining quiet if not understood. A few minor areas require including and are to be implemented by the manager following this visit. The service user guide as yet has not been reviewed but is to be undertaken shortly using photographic and picture referencing as well as using plain English written word. New contracts continue to be piloted in another area of the organisation to be easier to read and understand. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 The health, social and personal care needs of service users are encouraged offering regular contact with specialists and external professionals. Service users are treated with genuine respect and dignity by support staff. EVIDENCE: The acting manager has started to work with staff to implement MCCH care planning paperwork and systems, there are still some old records in place but this is being addressed. The file seen is large and cumbersome. Stream lining information would make this far easier to read and follow. Through discussion with a service users and sharing of their current care plan, it is clear that service users are given full support and encouragement to maintain personal contact with health and social care professionals, to maintain good standards of health and social care. Due to current behaviours being experienced additional assessments, guidance and staff training would ensure confidence that the care and guidance promoted is being managed appropriately. Records seen had some minor gaps in recording but staff stated the acting manager was working with them to address these. Reviews are taking place. Service users talked fondly and with familiarity to care staff on duty today and were able to instantly name their allocated key-worker. Medication was overall managed well and will be enhanced further by developing a clear protocol for handling medication when attending the day centre without decanting 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 11 medication. Records are stored securely and service users do not allow these to be share with others without their personal agreement. The acting manager and senior staff are keen to develop care plans further to be more photographic and object reference formats understood by the individual. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Community links are good and personal relationships and activities outside of the home are encouraged and maintained at the individual’s choice. The food prepared and provided is of good quality and served in accordance with service users’ own personal preferences. EVIDENCE: Service users are able to follow the hobbies and interests of their own choosing and the staff knows individual personal preferences. Care records reflect that a steady, though flexible routine occurs on a day - to -day basis and those in the home feel safe with this. Outings happen daily both planned structured sessions at local day centres, adult education as wells as more leisure opportunities such as the local pub as a particular favourite and having ‘lunch out’. Watching personal videos, TV, colouring, looking through magazines and other in house activities continue to be offered and are clearly enjoyed. Service users are actively choosing not to partake in activities together. A service user confirmed very regular contact with their direct and extended family through home visits and outings often staying overnight. Written feedback from relatives was received (included within the summary section). The kitchen was observed to be clean, well – equipped and stocked with fresh 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 13 produce and meals were served with ample portions. Meals looked wholesome and appetising. A service users responded clearly when asked if they liked the food with positive body language and nodding of their head. An ongoing issue of choice and personal withdrawal of eating is being managed well with G.P support. Staff however would feel more confident of their care with more specialist input and guidance to make sure they are doing the best they possible can. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 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 standard(s) 18,19,20 Intimate and personal care needs are attended to in a dignified manner and the physical and emotional health of individuals is promoted. Safe medication practices are followed but will be further enhanced through separate dispensing packs of medication sent to the day centre. EVIDENCE: Staff are clearly aware as to the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing. New medication storage has been implemented to comply with regulations. Staff have all received training and were confident of the system in place with regards the storage and administration of medicines. Records were inspected, with no errors noted. Further development of PRN guidelines would ensure consistent safe administration within clear set triggers and action to be taken. Current practice to re dispense daytime medication for the day centre should be reviewed with the pharmacist, to be dispensed in separate blister packs that can be sent weekly and withdraw the risk of errors and decanting medication. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 22,23 Service users express their views readily and are confident that staff act in their best interests. Adult protection policies and procedures give clear guidance in order for service users to be protected. EVIDENCE: Service users spoken with knew who to talk to if they had a concern or wished to make a complaint; this included their relative, key workers and the acting manager. Copies of a pictorial complaint procedure are available in the home but require specific local details of how to contact the commission. Staff who have been spoken with over a number of visits continue to evidence a good understanding of how to protect and prevent abuse, including reporting under local procedures. There are no current adult protection alerts relating to this home. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24, 25,26,27,28,29,30 Service users live in a warm, safe, clean home and garden, which will be enhanced further with the repairs to the bathroom and laundry facilities. EVIDENCE: The home continues to be presented to good standard of cleanliness and homely atmosphere. Service users talked of and undertook daily chores and cleaning within their agreed activity plan. Staff were supportive giving guidance and physical assistance where needed at a pace the service users could manage safely. Staff are required to completed tasks. The homes has one bathroom on the first floor that requires refurbishment and repair to broken tiles and cracked bath that pose as a high risk for infection control and injury to the users. The ground floor has an adapted shower room that is not used by current service users. The laundry cupboard continues to require attention to the walls due to ongoing flaking paint. The action manager evidenced further work requests to address this. The vacant bedroom is in need of urgent deep cleaning and removal of existing carpets and flooring due to the high offensive odours incurred. The garden is well maintained. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35,36 The home has sufficient numbers of confident and knowledgeable staff and team to support service users in their daily lives. EVIDENCE: The home has in the past year experienced higher turnover of staff mainly due to promotion within the organisation. Since the last inspection the home has successfully recruited new staff, thus offering more stability. The home has a whole time equivalent staffing level of 5 carers , senior carer and acting manager and is currently running with 29 hour vacancy. Due to the vacant bedroom this is not having an impact on current staffing ratios. New staff complete a full induction linked to TOPPS. Staff today presented as confident and approachable in their roles. Their commitment to the ensuring the safety and independence of service users was very evident in the manner, support seen during the visit. Excellent team working, communication and direct respect for each other was observed today. Of the current 6 care staff in post 4 have achieved NVQ 2, 3 or 4 in Care. Two staff member undertaking NVQ 3 and two staff looking to register for NVQ 3 and 4 in care. Staff confirmed that they are in the processing of updating and renewing mandatory training and applications have been submitted to the training department for processing. Acknowledgement letters were evident on 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 18 the new staff file for core mandatory training; some had already been completed in the past week. Regular one to one supervision is taking place the acting manager, with written records indicating all staff will receive at least 6 within 12 months. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,42 Service users and staff are benefiting from a motivated acting manager based at the home promoting a safe service and home. EVIDENCE: 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 20 Following eighteen months of changing managers (4 in all). The home has had a short period of time where an acting manager has been in post and made effective changes to the motivation and direction of care staff. The previous manager was only on secondment and promoted to service co-ordinator. The permanent post is due to be advertised in August and the successful candidate will be required to make full application to the commission as registered manager. The acting manager and senior carer presented as open and enjoying the dedicated time at the home and feeling of accomplishment to address concerns raised in the previous visit. The home has allocated team away day to explore the homes yearly goals and action plan. This represents their annual development plan. Formal surveys are not undertaken with service users due to the nature of service provided, however it is strongly recommended that formal surveys are undertaken regularly with other persons involved with individuals, such as visiting professionals, families and visitors to seek views and listen to issues advocated on behalf of the current services users rather than relying in the yearly formal review process. The commission has only received one regulation 26 visit report for June 2005. Formal environmental and fire risk assessments are in place. Weekly walking routes records are undertaken it monitors and report maintenance and health and safety issues for action. Regular servicing of equipment in the home is undertaken as required. Incidents, which affect the well being of service users, are recorded, with what action was taken. All recent incidents have been reported to Commission for Social Care Inspection (Kent and Medway) as required by regulation 37. 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 4 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Lenham Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 2 x x 3 x H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(1)(c) & Schedule 1 Requirement Timescale for action To be submitted to the commissio n by 30th September 2005 2. YA1 3. YA6 4. YA9 5. YA20 The Statement of Purpose must be reviewed to ensure compliance with the Care Homes Regulations 2001 and the revised National Minimum Standards. There is clear evidence that this has been addressed, a few minor amendments are required before this document is completed. 6(1) (2) The registered person shall produce a written guide to the care home(service user guide) which shall include all areas laid out in the revised National Minimum Standards 15(1) All service users care plans must set out in detail the action which needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the service user are met. (Ongoing work was evident today to working toward achieving this.) 13(4)(a-c) Risk assessments must be undertaken on all service users and the outcome recorded. (Ongoing work was evident as part of the care plan review) 13(2) The arrangements for the H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc 30th October 2005 30th October 2005 30th October 2005 30th August Page 23 3 Lenham Road Version 1.40 6. YA22 22(7)(a)( b) 7. YA30 23(2)(d) 8. YA27 23(2)(b) 9. YA39 26 (1)(3)(4)( 5) storage and transporting of daytime medication must be reviewed to ensure compliance with the relevant guidelines and not decant from blister packs to bottles. Ongoing options are to be put forward to pharmacist to dispense Day centre medication in separate blister packs. The complaints procedure must reviewed to ensure compliance with the Care Homes Regulations 2001 and the National Minimum Standards. The main complaints procedure has been updated but local pictorial formats do not include how to contact C.S.C.I local office. The registered person shall having regard to the number and needs of the Service Users ensure that all parts of the home are kept clean and reasonably decorated, by sanding down and repainting the flaking paint in the small laundry area. (Outstanding from the last two inspections) The registered person shall having regard to the number and needs of service users ensure that premises uses are kept in good state of repair internally, by replacing broken tiles and cracked bath in constant use by service users. The registered provider must undertake a monthly visit to the home that will be recorded and a copy of the report sent to the Commission for Social Care Inspection. (The commission has only received one copy for June 2005.) 2005 30th August 2005 30th December 2005 30th October 2005 30th uly 2005 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 24 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 YA1 Good Practice Recommendations It is recommended that:Ø The pictorial complaint procedure includes how to contact the Commission for Social Care Inspection (Kent and Medway.Ø Where the home does not meet NMS but is an existing home continuing to offer the same facilities as of 31/03/02, this is clearly detailed in the statement of purpose. It is strongly recommended that individual aspirations and goals be reviewed to reassess the appropriateness of the current living arrangements and compatibility of those living at the home through their person centre planning meetings. The statement of terms and conditions should be reviewed to ensure compliance with the National Minimum Standards. (On going from the last inspection) It is recommended that the main body of the care plan file be streamlined to hold only current information regarding the service user.Actual care plan with basic information is held at the front of the file with supporting records and information behind this.Risk assessments continue to develop (in an easy to complete and read format) to allow new opportunities whilst maintaining personal and individual safetyGoals and aspirations are service user led and individual to their social interests as well as maintaining independence. It is recommended that the pictorial complaints procedure be updated with the local commission address and telephone number.All concerns should be recorded with action taken It is recommended that Staff is familiar with the General Social Care Council Code of Conduct. A pictorial version is also available for Service Users with a learning disability. (Outstanding from the last two inspections) It is recommended that staffing rosters include the staff member’s full name and position held. It is strongly recommended that formal surveys are undertaken regularly with other persons involved with individuals, such as visiting professionals, families and visitors to seek views and listen to issues advocated on behalf of the current services users rather than relying in H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 25 2. YA2 YA6 YA 19 3. 4. YA5 YA6 5. YA22 6. YA31 7. 8. YA33 YA39 3 Lenham Road the yearly formal review process 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 3 Lenham Road H56-H06 S24086 3 Lenham Road V225995 040705 Stage 4.doc Version 1.40 Page 27 - 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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