Inspection on 09/05/07 for 31 Hadlow Road

This inspection was carried out on 9th May 2007.

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

Other inspections for this house

31 Hadlow Road 19/09/06

31 Hadlow Road 09/12/05

31 Hadlow Road 30/08/05

31 Hadlow Road 01/03/05

31 Hadlow Road 04/11/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 31 Hadlow Road Tonbridge Kent TN9 1LF Lead Inspector Eamonn Kelly Key Unannounced Inspection 9th May 2007 9:00 31 Hadlow Road DS0000023883.V336730.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.V336730.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.V336730.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 Ltd Mr Tony Smith Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2006 Brief Description of the Service: In its website, the Avenues Trust states that it “provides support for people with complex needs, including learning disabilities, autism, physical disabilities and mental health problems… We focus on individuals, establishing support that enables them to meet their needs and expresses their hopes and aspirations…. We support people in Kent, Medway, Surrey, Cambridge and a number of London Boroughs”. This residential home, one of several in the area owned by The Avenues Trust, provides accommodation and support for up to 5 people with learning disabilities. Resident’s accommodation is situated on ground and first floors. The premises are close to Tonbridge town centre. The weekly fees for new residents are £950 to £1500 depending on the level of care and support agreed at admission stage. Residents currently at the home have been placed under a block contract. There are a number of additional costs charged to residents details of which are shown in personal contracts. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 9th and 10th May 2007. It consisted of meeting with residents, the manager of the home and members of staff. Care practices were observed and discussed with members of staff. A variety of records was seen during the visit principally those that supported the care of residents. Some of the improvements requested in the previous inspection report have been implemented or are in the course of completion. Two residents were met at the home. The other two residents were on holiday at a UK holiday centre. The report contains information about progress made since the previous inspection visit and about how further improvement is necessary for the welfare and comfort of residents. What the service does well: What has improved since the last inspection? What they could do better: Prospective residents and their advocates should be provided with a revised copy of a resident’s guide. New residents and advocates of residents currently living at the premises should have a copy of a revised contract. The new resident’s contract should be personalised to reflect the agreed support required by the resident. Residents should have the benefit of a well run home. The shortfalls identified during the inspection must be appropriately addressed. This should include clarifying staff roles, improving the staffing position and providing sufficient management commitment to address shortfalls. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 6 The complaint’s procedure should be prominently displayed. Staff should receive better support in recognising potential signs of abuse including better knowledge of Safeguarding Adults procedures, POVA and equality & diversity. Residents and staff should have the benefit of safer and more comfortable premises. Care plan records should be used as effective operational tools with appropriate benefit for residents and members of staff. 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. 31 Hadlow Road DS0000023883.V336730.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 31 Hadlow Road DS0000023883.V336730.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, 2, 3, 4, 5. Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service People who use this service receive some information about the home in order to make an informed decision about whether the service is right for them. A better Resident’s Guide and a more appropriate personal contract would help them with this decision. EVIDENCE: Most residents have lived at the premises since it opened in 1988. One resident moved to another residential home near North Wales in November 2006 and consideration has been given in the meantime to admitting a new resident. The manager outlined how prospective residents receive a detailed assessment of their personal care needs and how they might participate in a planned programme of introduction and visits to build on relationships with current residents. This would lead to, with the involvement of advocates and family members, trial visits and over-night stays prior to a final decision being made. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 9 Because of the routines built up by residents over a long period since they moved under a block contract with Social Services from a long-stay hospital environment, it is likely that considerable reflection is needed before admission of a new resident. There is some dependency of a range of restrictive practices that could be detrimental to new resident’s interests. These are referred to later in this report. A file containing information about the home and its facilities is made available to prospective residents and their advocates. This information is relatively unhelpful in explaining the nature of procedures, services and facilities. Personal contracts are similarly unhelpful although they are used widely by the Trust. For example, some 20 items are shown as being capable of being debited to resident’s accounts. Any new contract for new residents should contain the information required under the national minimum standard and should be personalised to that resident. The manager recognises the issues that need to be carefully examined before admitting any new residents. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Members of staff assess resident’s support needs and residents are helped to lead productive lives. This support would be improved by better procedures for identifying planned improvements and measuring progress towards these outcomes. EVIDENCE: Care plan records include good profiles of each resident’s disposition and support needs. Person centred plans that include photographic evidence of their capabilities and activities enable staff in theory to have a holistic view of resident’s progress. Members of staff have a good insight into the challenges faced by each resident and of how support is provided to meet their needs and aspirations. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 11 However, the examples of risk assessments seen were difficult to follow although improvements have been made to these since the previous inspection. Staff are aware that incidents which occurred in the past need to be avoided or minimised in the future for the protection of residents. However, this has resulted in a range of restrictive practices. The kitchen door, manager’s office, laundry, and storage cupboard have baffle locks. A cupboard in the kitchen where biscuits are stored is locked. The base to the electric kettle is locked in the manager’s office when not in use. The door leading to the staff sleep-in bedroom is adapted to prevent a resident who moves about at night from disturbing the sleeping carer. Toilet paper is placed on a shelf at ceiling level because a resident sometimes blocks the drains with paper. The gate at the front is fitted with a padlock. Personnel files held in an “Envopak” containing staff information is held in a locked cabinet with a covering note requiring CSCI inspectors to witness the resealing of the envelope. If this high level of restriction is necessary, it is reasonable to assume that residents have very significant support needs. It would be expected that appropriate staff numbers are available to supervise residents at all times. However, there are only 15 per week of management time allocated in two work shifts and there have been staffing problems for some time. It would also be more appropriate to have a system of identifying planned improvements and measuring progress towards these outcomes rather than depending on simple coping mechanisms that have developed over the years. Residents would then be assisted to make decisions about how to lead their lives and maintain relatively independent lifestyles. They would benefit from involvement in care plans and risk assessments that are regularly reviewed. Resident’s have complex communication difficulties and disabilities. The manager discussed possible new approaches to maintaining care plans and risk assessments. Each resident is known as an individual with specific needs and capabilities. The person-centred planning approach could be enhanced by the use of “shift planners” for each day. This would highlight progress towards simple goals. For example, a scoring system related to progress in identified and agreed for simple task that day could be a working tool to help staff identify support needs and provide the types of assistance needed. This approach is more labour intensive and requires specific staff training and supervision to achieve. Supervision is not currently a strong element of procedure as the manager and a senior support worker carry out formal supervisions between them. Capabilities and preferences would be better taken into account as part of the home’s procedures for supporting residents. Members of staff would have the 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 12 objective of helping residents to make improvements, however small, and for these to be identified. The progress made by a key worker in one case indicated that the home is moving towards procedures that sets small targets for improvement, however, small, and works towards achieving progress over time (ie. towards the concept of shift planners) . 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 13 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): 11-17. Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents receive encouragement and support to make choices about a range of local social and recreational interests at a pace suitable to them. EVIDENCE: Residents are able and encouraged to develop interests of their choosing and staff know individual preferences and capabilities. Care records and the programme of activities displayed suggest steady flexible routines occur each day. Daily outings provide leisure opportunities such as visits to a local favourite pub, lunches out, swimming, cinema, playing football and bowling. There are trips to theatre, shows, daytrips to the coast and elsewhere. Photographs of recent events are displayed in bedrooms and in resident’s care records. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 14 Residents are able to collect and watch DVD’s and listen to music in their bedrooms or communal area. A resident demonstrated how he plays drums and a synthesiser in his bedroom. On the days of the inspection visit, 2 residents were on a week’s holiday at Centre Parcs in Norfolk accompanied by 2 members of staff. Structured leisure and work experience is obtained through Riverside day centre and elsewhere. The previous inspection report referred to holidays being planned with staff talking to residents and their families and seeking venues that cover their personal choices and interests. Contact with families and relatives is promoted through visits to their relative’s home, relatives/friends visiting the premises, telephone calls and letters. According to a member of staff, the menu provides a varied variety of meals with some fruit and vegetables grown in the garden. There is evidence that meals are made to the specific likes and dislikes of individual residents. Residents are involved in preparing shopping lists and purchasing foods locally. They assist with some aspects of preparing meals as part of contributing to work routines. This progress can be variable given the support requirements of most residents. However, it is likely that this aspect of resident involvement will be better incorporated if further progress is made on “shift planners”, the concept of which was outlined in the previous section of this report. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Members of staff treat residents with understanding, respect and dignity by. Their health, social and personal care needs are supported with regular contact with health and social services staff. EVIDENCE: Members of staff understand the type and nature of support required for each resident’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. There were significant shortfalls in procedures observed during the inspection visit but staff quickly addressed these. The manager stated that policies and procedures covering gender issues would be reviewed as a matter of some urgency. Care plans and discussions with staff suggest a good understanding amongst the staff group of individual physical and emotional needs. Discussions with 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 16 resident’s care managers following the inspection visits suggested that the needs of residents are being met but that further improvements are expected to be benefit to residents and staff. Please refer to the next section of this report. Following the previous inspection report, improvements were made to how medicines are stored and administered. Emphasis is also placed on accurate recording of administrations in MAR sheets for the continuing safety of residents. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Protection of residents from abuse is promoted through staff training and some understanding of the support and actions they may need to take. However, residents would be further protected if supporters and visitors have access to a prominently displayed complaint’s procedure and all members of staff have a better understanding of important procedures such as Safeguarding Adults and equality & diversity. EVIDENCE: On the first day of the inspection, members of staff were unable to provide a copy of a complaint’s procedure and such a procedure is not prominently displayed. Members of staff on duty were unable to demonstrate a proper understanding of how to identify possible signs of abuse and how to report any suspicions. Records indicate that no serious complaints arose since the previous inspection. However, during the fist day of this inspection, the commission reported a serious shortfall in procedures relevant to the safety of residents (and possibly of staff) to Social Services department. The Avenues Trust undertook to investigate the occurrence. This demonstrates a commitment to investigating complaints. Social Services department advised the commission that a Safeguarding Adults conference was necessary to assess if procedures at the premises are sufficiently effective to protect residents. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 18 Previously, the trust investigated concerns raised and it has experience in referring individuals where necessary to the POVA manager’s office for further investigation. Members of staff receive mandatory training in Safeguarding Adults procedures but on this occasion there was evidence that practices need to be improved. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 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 comfortable but uninspiring environment. They would benefit from improvements to the state of the kitchen and redecoration of some parts of the premises. EVIDENCE: There is some reluctance by the Avenues Trust to upgrade the premises. Kelsey Housing is responsible for maintenance. During the inspection, a support worker was redecorating bedrooms. A maintenance schedule was not available. Following the previous inspection, the commission requested the manager to obtain environmental health and infection control reports for the premises. April 2007 staff meeting minutes state that a new kitchen would be installed. No actual plan exists for this proposed development. Following 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 20 receipt of the draft inspection report, the commission was advised that this refurbishment is imminent. During this inspection, the premises were not as well maintained as would be expected. The kitchen, as referred to above, needs extensive modernisation to promote food hygiene practices and infection control. There are good garden facilities including a vegetable patch that partly supplies the home. The garden area at the front of the premises is not well maintained. Cleaning materials are stored in three places: in the kitchen, in a locked cupboard under the stairs and in the garage with laundry equipment and food storage (in this instance without adequate separation). Members of staff are aware that some residents would drink any chemicals left unattended and they take precautions to prevent this. A 1st floor WC does not have a hand-basin: this presents a potential infection problem. As the room is too small for a new hand-basin, an alcohol gel dispenser will soon be fitted. Residents are unable to have normal access to flannels, paper towels and toilet paper in bathrooms because a resident sometimes blocks the drains if these items are made readily available. As part of better support procedures for all residents, it is possible that this situation will be addressed so that resident’s lives are normalised as far as possible. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31-36. Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service Residents are in the care of members of staff who are enthusiastic and hardworking. Members of staff are working towards helping residents live safe and contented lives. The manager and members of staff need better clarity of staff roles and responsibilities to enable residents to be supported in accordance with their needs and capabilities. EVIDENCE: There is some over-reliance on agency and “bank” staff. There was evidence that this procedure is not benefiting residents or staff during the inspection visit. The home is experiencing staffing difficulties and this was also the position when the previous inspection took place. Somewhat strangely, staff information is kept in an “Envopak” with a covering note requesting CSCI inspectors to witness the resealing of the container. However, there are no proper staff files available. Avenues Trust staff at its office in Sidcup carry out recruitment. The manager understands that relevant 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 22 information will be provided to him in due course in relation to the requirement that registered homes must keep relevant staff information necessary for the proper running of the premises. The manager does not, for example, have a list of staff with relevant information about completed CRB checks. The previous CSCI report referred to the need for up-to-date staff files to be maintained but further progress has not been made in achieving this. Because of the pressure of time on the manager, supervision is shared with a senior support worker. There was some evidence that this procedure is not an effective way of carrying out supervision as a means of helping to ensure that the actual needs of all residents are being effectively met. The information available to prospective residents and their advocates suggests that all members of staff have received appropriate training. The first section of this report outlines how accurate information is required to be presented in a revised resident’s guide. The current position is that not enough progress is being made in enabling support staff to obtain NVQ Levels 2 and 3 in Care/Supporting Independence. The training matrix available is not up-todate and it is difficult to judge the quality of training purported to have been obtained by each member of staff. The manager says he will, in the revised resident’s guide and individual staff files, maintain an up-to-date account of NVQ training achieved by each member of staff, the actual “mandatory” training undertaken and when and other significant certificated training appropriate to the direct care of residents at the premises. Members of staff say that there is strong emphasis on training within the Avenues Trust and they are encouraged to take up the opportunities offered. Reference to the new work being undertaken by a key worker indicates that there is a commitment to looking at better ways of supporting residents. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42. Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are not supported effectively by management and administration procedures. Better monitoring of conditions and improvement of procedures is needed for their benefit and that of members of staff. EVIDENCE: The registered manager, Mr Tony Smith, has achieved the Registered Manager’s Award, Certificate in Management Studies and NVQ Level 3 in Care and has significant experience of working with people with learning and physical disabilities. 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 24 There are only 15 hours per week (during 2 shifts) allocated for management and administration of the home. Mr Smith works as a support worker on early, late and night shifts for the remainder of the time. The level of professional support that should be in place for residents with the degree of supervision and care they need was not witnessed during this inspection. Some improvements resulted from the last inspection but insufficient progress has been made. The response to the previous inspection report indicates some commitment by the Avenues Trust to address quality assurance issues. The manager also on this occasion demonstrated a good knowledge of what needs to be improved. Staff met are enthusiastic and hardworking. Visits and reports by a visiting Avenues Trust manager are available but these, whilst detailed, have not led to sufficient action being taken to address shortfalls. The premises are subject to on-going maintenance. Despite this work, the premises generally are lacklustre and uninspiring. The kitchen continues to pose hygiene and other risks. The support requirements of residents include a number of restrictive practices. Whilst staff are enthusiastic and hardworking, there is reliance on agency and bank staff and, as seen during the inspection, poor staffing levels on occasions. The latter referred to one member of staff on duty with a male and female and where diversity considerations were a relevant factor at the time. Some procedures do not support the concept of best practice for caring for people with learning disabilities. In many respects, the manager feels that he does not have full control over issues because of corporate policies and the nature of his part-time involvement. The response therefore is to cope as best as possible with ensuring the day-to-day safety of residents. Whilst this is important within a risk assessment framework, other considerations are also important to enable residents develop appropriately within a more advanced support environment. 31 Hadlow Road DS0000023883.V336730.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 2 2 3 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 x 27 2 28 3 29 x 30 3 STAFFING Standard No Score 31 2 32 2 33 2 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 1 2 2 2 x 3 x 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1YA1 Regulation 4, 5 and 6. Schedule 1. Requirement All prospective residents and their advocates must be provided with a copy of a revised resident’s guide. This should be produced in the order shown in Schedule 1, contain the information required and as discussed during the inspection visit. Care plan records must be used as effective operational tools with appropriate benefit for residents and members of staff. Residents must have the benefit of a well run home. The shortfalls identified during the inspection must be appropriately addressed. This should include clarifying staff roles, improving the staffing position and providing sufficient management commitment to address shortfalls in the short and longer term. Timescale for action 30/08/07 2 YA6YA6 14, 15, 17. 18, 24. 30/08/07 3 YA31YA31 YA37YA37 30/08/07 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 27 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 YA22YA22 YA23YA23 Refer to Standard YA24YA24 Good Practice Recommendations Residents and staff should have the benefit of safer and more comfortable premises. The complaint’s procedure should be prominently displayed. Staff should receive better support in recognising potential signs of abuse including better knowledge of Safeguarding Adults procedures, POVA and equality & diversity. New residents and advocates of residents currently living at the premises should have a copy of a contract that contains the information outlined in National Minimum Standard 5.2. The new resident’s contract should be personalised to reflect the agreed support required by the resident with a new contract issued if the level of support needed and agreed significantly changes. 3 YA5YA5 31 Hadlow Road DS0000023883.V336730.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 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 31 Hadlow Road DS0000023883.V336730.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!