Inspection on 19/09/06 for 31 Hadlow Road

This inspection was carried out on 19th September 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

31 Hadlow Road 09/05/07

31 Hadlow Road 09/12/05

31 Hadlow Road 30/08/05

31 Hadlow Road 01/03/05

31 Hadlow Road 04/11/04

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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 31 Hadlow Road Tonbridge Kent TN9 1LF Lead Inspector Lynnette Gajjar Unannounced Inspection 19th September 2006 09:25a 31 Hadlow Road DS0000023883.V303159.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 31 Hadlow Road DS0000023883.V303159.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. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 31 Hadlow Road Address Tonbridge Kent TN9 1LF 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) 01732 770834 The Avenues Trust Limited Mr Antony Edward Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 31 Hadlow Road is registered to provide care and accommodation for five people who have learning disabilities. The Avenues Trust owns the home and Mr Antony Smith is the Registered Manager. The home is located within walking distance of Tonbridge town centre with good access to local amenities and public transport systems. The property is a detached house with resident accommodation on two floors. In addition to residents’ single bedrooms, there is a small bathroom and toilet, a shower room and a separate toilet. There is a lounge, dining room and kitchen. Laundry facilities are located in an outbuilding adjacent to the house. There is also a large garden mainly laid to lawn and a patio area. The home has parking area for 4/6 cars. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key unannounced inspection, for the year running from April 1st 2006 to March 31st 2007. The visit lasted from 09:35am until 17:25pm. The home has 5 people in residence who have lived together for a number of years, three since 1988 when the home was opened. The visit was spent talking with four residents who were at the home, with staffs interpretation through their individual communication methods, however communication was limited. Time was spent observing direct interaction and support with staff and residents, talking with three care workers and the registered manager. Due to the planned activities two residents were a day activities all day. The inspector accompanied the remaining three residents and staff for a lunch out activity. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of the resident in the report. Some judgements about quality of life and choices were taken from direct conversation and physical responses with people living in the home as well as direct observation followed by discussion with staff, evidencing records and care plans held at the home. A tour of the house was undertaken. A number of CSCI “comment cards” (completed questionnaires) were received from 5x relatives/visitors; 1x care managers, 2x Health Care professionals and 2x GP’s. The report also uses information provided by the manager through a detailed questionnaire. What the service does well: Residents benefit from a staff team who work well together, promote a happy and familiar support for individual residents. Staff know the individuals well and communicate effectively with them. Residents presented as feeling safe and comfortable at the home. Residents have a happy and fulfilled lifestyle with good two-way relationships and contact with their families. Feedback received from five relatives/carers concluded that they were overall satisfied with the care given and other professionals comments included: “Staff are supportive and caring. Clients are very relaxed in their presence.” “Generally well and see once a year for review” 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents would benefit from staff having clear written guidelines and information for all PRN medication, particular attention to the safe storage of internal and external medication separately, having a safe and accountable system for monitoring and returning medication that is near or past it’s expiry date. Staff should undertake full medication competency assessments at least once a year and adhere to company policy for medication storage, administration and disposal. Residents would be safer with the resolution of inadequate and unpredictable hot water supply from the kitchen tap. Residents living on the ground floor would feel more secure and safe with window restrictors fitted to their windows. Staff can develop further the daily records and diaries by ensuring accurate details of the support and care given, how the residents have felt, been involved etc, to reflect the guidelines and assessed plan of care. For the ease of tracking and completing care plans, a review of current duplication of risk assessments and guidelines and their storage would reduce the risk of confusion to the most recent and accurate documents to follow. Through the refurbishment of the kitchen units, work surfaces and tiles staff and residents can promote good infection control and basic food hygiene requirements. Residents would find the home more homely, through the redecoration of the woodwork, the bathrooms and communal hallways being completed. Recruitment should continue to fill the support worker vacancies currently in hand to offer consistency and familiarity to residents. Through further information sharing relatives and representatives would have a better understanding of the homes compliant procedure. Residents and staff would feel more secure in the knowledge that alternative filing of accident/ incident records is given serious consideration and stored to ensure compliance with Data Protection and protect confidentiality. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 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. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: The home has not had any new admissions for the past 5 years, with three of the residents having lived together since it’s opening in 1988. The manager and staff continued to show a good understanding of the referral and admission process managed by Avenues Trust. Where by any prospective resident would undertake a formal assessment of their personal care needs, social interests, a work through a planned programme of introduction and visits to build on relationships with current tenants, leading to trial visits and over night stays prior to a decision to move into the home is made. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Person centred care plans, risk assessments and guidelines continue to develop offering information to ensure consistent support by staff in meeting the individual health and social care needs. Better tracking and storage systems would reduce the risk of duplication and potential to miss information. EVIDENCE: Through discussion with a staff and assessing two current care plans, it is clear that those living here 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. Guidelines and risk assessments enable staff to access information that is most important and to maintain individual and collective goals safely. However different filing systems away from the care plan leads to duplication, leading to potential risk of missed reviews and access to the latest information. Photographic, pictorial and object referencing is used to aid communication and better understanding by the residents in a smaller file. This was shared 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 11 with one resident who took great pleasure and obvious familiarity with the documents promoting good interaction and promoting their self esteem, despite their limited communication. Daily diaries are kept for each person by staff. A more specific summary of the care and support given and reciprocated would reduce duplication with record sheets kept separately for the trusts monthly returns. In house care reviews take place at least 6 monthly. Personal money is kept securely in the home. Records are kept of the money put in and taken out. For additional security the cash tins are signed by staff after they have opened them and checked on each handover. Independent formal audits are not undertaken of personal monies. Interaction between the residents and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Records seen were stored securely. To comply with Data Protection alternative storage of the yellow accident form was discussed and implemented by the manager. 31 Hadlow Road DS0000023883.V303159.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are given encouragement and support to make choices about a range of local social and recreational interests at a pace suitable to them. The menus and food provided offers quality, nutritional value and healthy fresh products. Allowing them the right to exercise choice and control over their diet. EVIDENCE: Residents are able and encouraged to follow hobbies and interests of their choosing and the staff know individual personal preferences. Care records reflect that a steady, though flexible, routine occurs on a day - to -day basis and individuals feeling safe with this. Outings happen daily offering leisure opportunities such as the local pub as a particular favourite, having ‘lunch out’ and swimming, cinema, playing football and bowling. Other trips to theatre, shows, daytrips to the coast were discussed with residents and photographs of recent events discussed with one resident. As well as more relaxing watching personal videos, TV, and listening 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 13 to music. Due to personal experiences some individual’s participation in local activities and outings can cause anxiety but this is being encouraged and supported to increase opportunities at a pace suitable to the individual, including holidays. There are planned structured sessions at the home with individual tuition for drums and guitar. Structured leisure and work experience is obtained through Riverside, Pepenbury and Adult Education. Holidays are being planned and staff described how they are talking with individuals and seeking venues that cover their personal choices and interests and then searching the Internet for some matches. Contact with families and relatives are promoted on an individual basis, through visits to their relative’s home as well as here, outings, telephone calls and letters. The menu offers a varied and wholesome variety of meals, with ample fresh fruit and vegetables (picked today from the garden included Marrow runner beans and potatoes). Meals are made to the specific likes and dislikes of individuals. Clear support and guidelines for assisting individuals are in place, that are personal, respectful of preferences and special support needs to make mealtimes an enjoyable time. Direct observation whilst out on an activity showed mealtimes to be at a pace comfortable to the individuals. Residents are encouraged to be involved in write shopping lists, purchase foods locally and be involved in the preparation and cooking of foods to the best of their ability although this can be limited and required staff supervision at all times. 31 Hadlow Road DS0000023883.V303159.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 on this outcome area is Adequate. This judgement has been made using available evidence including a visit to the service. Residents are treated with genuine respect and dignity by care staff. Their health, social and personal care needs are supported with regular contact with specialists and external professionals. Residents are at risk and potential harm due to the poor storage and disposal of medication held at the home. 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. Care plans indicate staff have a good understanding of individual physical and emotional needs. Poor practice in relation to medication management and storage was identified. MAR Sheets are clearly written, hold photographs and have PRN guidelines of administration except for two items that require these to be written. Internal 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 15 and external medication was stored together resulting in tablets being covered in oils. Staff recorded assessment of competencies are over due. There is no formal auditing or monitoring of medication management at this home, putting residents at potential risk of being given contaminated or out of date medication. This had been identified at the last inspection. 31 Hadlow Road DS0000023883.V303159.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 on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse is promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Due to the nature of the service and those living here, using this system is limited. It is evident for the majority, they would be heavily reliant on a relative/ advocate/staff to identify concerns and raise them on their behalf. Of the five relative comment cards and feedback; two expressed that they were unaware of the homes complaint procedure. The home’s records indicate they have not had any formal complaints. Staff who have been spoken with evidenced a good understanding of how to protect and prevent abuse, including reporting under local procedures. Staff have completed training in this area. There have been two Adult Protection alerts and investigation at this home since the last inspection. One resulted in a staff member being suspended from their post, subsequent dismissal and referral to the POVA list. The other is currently still under investigation and awaiting a strategy meeting to discuss the outcome of the investigation and action to be taken. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 17 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): 24,25,27,28,29,30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a clean, comfortable and homely environment, which would be enhanced further by the replacement of kitchen doors/work surfaces and the ongoing internal redecoration of woodwork and communal areas. Residents are at risk of scalds due to the hot water kitchen tap not working properly. EVIDENCE: The home is a large detached property, well presented, and bright, with adequate internal and external space and equipment for those living here. There are good standards of cleanliness. The dining room and communal areas are on an ongoing redecoration programme. Individual bedrooms have been decorated to their needs and tastes and contain their personal possessions. Residents have the use of a lounge and dining room that are comfortably furnished and has a TV, video, DVD and music centre. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 18 The kitchen doors and work surfaces are in need of replacing to promote good food hygiene practice and infection control management. The hob and oven have been replaced since the last inspection. The kitchen tap is a hazard as it is not working properly; with no hot water coming out when switched on, if left after a few minutes hot water suddenly bursts from the tap. This is intermittent and dangerous. It has been reported to the housing association but no action has yet been taken to rectify this. There is a shared bathroom and separate shower cubicle (the latter requiring a deep clean) and monitoring of mould patches in the bathroom. The laundry is located in the garage; access is required through the kitchen and covered area or going out the front door through two locked gates to access from back door of the garage. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 19 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): 32,34,35,36 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Resident’s benefit from a core long-term staff team that receives training and supervision in meeting individual needs of those living at 31 Hadlow Road. Residents will benefit further from stabilizing of the staff team through current recruitment to vacant posts. EVIDENCE: Staffing rosters have reflected changing care needs of individuals. The home is currently running with 2 staff vacancies. A regular agency worker and bank staffs cover this. The home will benefit from the stabilizing of staff team through two new staff. Staff files are held at head office. Typed forms are sent to the home that hold details of references received, CRB Number and disclosure, personal details etc. Those seen today were printed in 2003. A number of staff has worked for the organisation since 1991and were transferred from local government. Therefore references were not available as employed by the previous company. Gaps in two staff CRB records are to be chased by the manager with the Human Resource Dept. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 20 The organisation continues to encourage and support care staff to complete their NVQ 2 and 3 in care. The home currently has 3 of the 8.5 staff holding NVQ 2 or 3 in Care. Staff competency assessments for medication practice are overdue. Staff feel supported by the manager. Supervision takes place at least monthly. Care staff spoken with and directly observed evidenced clear and good understanding of different individual care needs. Residents reacted fondly towards individual staff and their help. With positive conversation, appropriate touch and nodding and shaking of heads to yes/no to conversation with the inspector. Staff were seen to support individuals respectfully but also with respectful familiarity resulting in some fun joking and banter from both parties. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 21 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): 37,39,41, 42 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents have their personal preferences, support and care needs encouraged through the registered managers open leadership but this would be enhanced further by more robust monitoring and auditing systems to promote a safe home and working environment. EVIDENCE: The registered manager has been in post for some time and has considerable experience of working with this resident group. The manager’s qualifications include the Registered Managers Award, Certificate in Management Studies and NVQ 3 in Care. The manager continues to demonstrate an open approach to the running of the home and an enthusiasm for positive change. Staff spoken with and feedback from relative comment cards support this view. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 22 The manager is accountable to the Service manager who visits monthly to audit the service. A review of window restrictors not fitted to ground floor bedroom windows that are accessible by the public should be undertaken to promote the resident’s security and personal safety. Through more robust monitoring and auditing of care plans, risk-assessments and health and safety practice, the health, safety and welfare of residents would be better protected. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 23 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 3 3 X 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 2 25 3 26 X 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 2 LIFESTYLES Standard No Score 11 X 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 1 X 3 X 2 X 2 2 X 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 24 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 YA10 Regulation 17 Requirement Records 17 (1) (b) In that accident /incident records are filed to comply with data protection and freedom of information Acts. Full improvement plan with proposed completion dates to be submitted by 31/10/2006 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home in that: 1) There is a formal procedure for monitoring and disposing of medication and their expiry dates. (Medication identified is returned and replaced within 7 days of the inspection) 2) Internal and external medication is stored separately. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 25 Timescale for action 31/10/06 2 YA20 13(2) 27/09/06 3 YA24 13(4) 3) All PRN medication has clear guidelines of administration. 4) Staff undertakes regular assessments of competency in medication practice. Full improvement plan with proposed completion dates to be submitted by 27/09/2006 The registered person shall 31/10/06 ensure that— (a) all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety; (b) Any activities in which residents participate are so far as reasonably practicable free from avoidable risks; and (c) Unnecessary risks to the health or safety of residents are identified and so far as possible eliminated, In that the hot water tap to the kitchen tap is made safe and in good working order. Full improvement plan with proposed completion dates to be submitted by 31/10/2006 31 Hadlow Road DS0000023883.V303159.R01.S.doc 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 YA6 Good Practice Recommendations It is recommended alternative methods be explored to ensure accurate reflection of the care and support provide is recorded daily. Current records do not show this or are dotted around in different places making it difficult to track and review. It is recommended that audit and review sheet is set up in each section of care plan to aide staff in record management. It is recommended that the storage and duplication of risk assessments and guidelines be reviewed to develop a clear tracking system. It is recommended that relatives and advocates be given copies of the homes complaint/compliment procedures for their familiarity and reference. It is strongly recommend the organisation continue to redecorate the communal areas and woodwork. It is recommended that the shower be deep cleaned and the bathroom decoration be closely monitored due to the damp patches presenting on the ceiling. It is strongly recommended that kitchen doors and damaged work surfaces be replaced to promote effective food hygiene and good infection control management. It is recommended support and advice be sought from the Infection Control Nursing Team regarding the above and promote general good practice of infection control management in the home. It is strongly recommended that the home continue to work towards achieving 50 of the staff team to be trained to NVQ 2 in care or equivalent. It is strongly recommended that recruitment to permanent 2 staffing posts be implemented as quickly as safe recruitment procedures will allow. It is strongly recommended that an auditing and monitoring system is introduced to staff files held at the home to ensure up t date information is held here. It is strongly recommended that staff files that do not hold current CRB clearance information be rectified with the Human Resource team. It is strongly recommended that the manager and service DS0000023883.V303159.R01.S.doc Version 5.2 Page 27 2 3 YA6 YA9 4 5 6 7 8 YA22 YA24 YA27 YA30 YA30 9 10 11 12 13 YA32 YA35 YA35 YA35 YA39 31 Hadlow Road 14 15 YA39 YA42 16 YA42 manager ensure effective quality assurance, auditing of practice and records are undertaken, with clear action points and monitoring to ensure the wellbeing, health and safety of residents and staff. It is strongly recommended that the manager accesses the updated and amended Care Home Regulations June 2006 and is familiar with the changes made. It is strongly recommended that the risk assessment be reviewed for window restrictors to be fitted to the ground floor bedroom for personal safety and security of the residents living there. It is recommended that a clear protocol and responsibilities are set and understood by all parties in notifying the Commission, of incidences and action taken that are managed by head office and senior management staff. 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 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 31 Hadlow Road DS0000023883.V303159.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!