CARE HOME ADULTS 18-65
32 Kentish Road Freemantle Southampton Hampshire SO15 3GX Lead Inspector
Christine Hemmens Unannounced Inspection 29 September 2005 11:00a 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 32 Kentish Road Address Freemantle Southampton Hampshire SO15 3GX 023 80 701227 023 80 772007 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) Southampton City Council Mrs Nicola Jane Ward Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th February 2005 Brief Description of the Service: 32 Kentish Road is a Local Authority Home provided by Southampton City Council. The home offers respite care to seven younger adults who have learning disabilities and associated physical disabilities. The home recently opened following a major refurbishment. Improvements have been made to the environment and two rooms situated on the ground floor now provide on suite facilities to accommodate service users with physical disabilities associated with their learning disability. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first visit to the home since it reopened following its refurbishment. The registered manager was not available for the first part of the visit, however the homes administrator, two staff and a service user assisted the inspector. For the purpose of the visit the inspector viewed service user and staff records and undertook a tour of the building. As the majority of the service users where out at the time of the visit limited contact and views were obtained, however the inspector has agreed that the next visit will be undertaken in an evening or weekend when service users will be in. What the service does well:
Kentish Road does well to provide the service users and their relatives/representative with accessible information about the service, its facilities, available activities and the rights of the service user during their stay. It does well to provide a service that ensures it can meet the assessed needs of the service user and their relatives before agreeing to support them. It undertakes a thorough assessment and develops clear and detailed personal plans and risk assessments that reflect the service users strengths and needs. The service works with the service user, their relatives/ representatives and health care professionals to ensure the stay is made comfortable, mirrors daily routines and activities, and maintains and develops individual skills. Service users are supported to undertake activities of their choice whilst staying at Kentish Road such as going to the cinema, the pub, shopping or engaging in activities in the home such as watching videos, listening to music or playing pool. The service user can continue to attend day service, college and or work if they wish. One service user had opted to have a “lazy day” at the service and said that she really liked staying at Kentish Road because the staff are very nice and she could do what she wanted. The service does well to provide well-balanced and nutritious meals, which, the service users are supported to choose, they are provided with assistance when required. Kentish Road does well to support service users with their personal care in a way that they wish and accesses primary and specialist health care teams to
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 6 assist with the support and training of staff in assisting service users’ with their physical and emotional needs. The service has developed an accessible complaints procedure and does all it can to protect service users from potential risk of abuse. The staff are equipped with the skills to listen, observe and report any concerns the service user may have or demonstrate through their behaviours. The staff are observed to demonstrate good values and interact well with the service users. Kentish Road provides a spacious, clean and well-equipped environment that promotes the service users independence and individuality. The recent refurbishment of the service has enabled the staff to support service users with physical needs (associated with their learning disabilities). En-suitfacilities, moving and handling equipment and touch sensors for two of the designated doors are in place. Kentish Road does well to recruit staff with good values and an understanding of their roles and responsibilities, staff receive appropriate training and are encouraged to undertake a National Vocational Qualification (NVQ). The staff with whom the inspector met said they enjoyed working at Kentish Road and felt well supported by the manager and one another. The manager does well to deploy staff in appropriate numbers and skills to meet the numbers and needs of the service users during their stay. Staff are flexible and do not mind doing extra hours when required. What has improved since the last inspection? What they could do better:
Generally the home provides a very good standard of care for the service users and relatives who receive respite, however the inspector observed a small number of areas where the service could improve. The service has received five requirements and four recommendations following this visit. The home could do better to ensure that all service users have risk assessments undertaken for them especially those who have been placed as an emergency. The service could do better to ensure service users and their relatives/representatives are provided with the correct information on other agencies they can take their concerns and complaints to. The complaints procedure should read the Commission for Social Care Inspection and not the National Care Standards Commission. The manager is advised in the interim to inform service users and relatives/representatives of the change.
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 7 Despite a recent refurbishment of the service, some areas of the home were not included, the inspector found the shower basin of the upstairs bathroom to be grimy and the seal perishing, a damaged toilet seat and dirty shower on the ground floor, therefore the manager must replace the shower basin, replace the toilet seat and ensure all bathing facilities are thoroughly cleaned after use. The manager does well to deploy staff to meet the numbers and needs of the service users, however the service currently has five vacancies which if not filled soon could have a detrimental effect on service users and staff. Kentish Road does well to keep service users as safe as feasibly possible whilst staying at the service, however the home could do better to ease accessibility to service users allocated bedrooms by installing an appropriate mechanism for holding open bedroom fire doors and enable them to leave open their doors if they wish. 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. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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): 1,2 and 5 Kentish Road does well to provide service users and their families with information about the service and their rights of terms and conditions. The service obtains information about the prospective service users to ensure it can meet their needs. EVIDENCE: The service has developed a very good example of a Service User Guide that has been clearly and simply laid out and made accessible by using pictures and photographs, this provides information about the service and the facilities available. The manager informed the inspector that some service users, including those with sensory disabilities had been consulted and involved with the aid of an advocacy service to develop the guide. The manager also stated that if it were required the service would provide the guide in other formats such as audio and video to meet cognitive and sensory needs of service users, however currently staff are encouraged to use the Service User Guide as a working tool with service users to make them aware of the facilities, services and their rights. An easy to read leaflet, produced in bullet point form with pictures and useful contact numbers has also been produced by Southampton City Council. The home undertakes a thorough assessment of prospective service users and obtains a care management assessment to assist with this process. The assessment is comprehensive and views the holistic needs of the service user 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 10 such as strengths, needs and personal and any special needs he service user or their families may have. Each service user is issued with a statement of terms and conditions, which states the rights and expectations of the service user, in addition the service has developed a charter of rights for the service users, which has been produced in an easy to read format. However the service may wish to consider providing the contract and charter of rights in a similar format to the Service User Guide. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 11 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 and 9 The home does well to develop clear and detailed personal plans and risk assessments based on the assessed needs of the service users. However the service must ensure all service users have risk assessments identifying areas of concern and need. EVIDENCE: The inspector viewed three service user personal plans. Personal plans hold key information about the service user such as their DOB, contact details and personal history. Personal plans clearly detail the service users’ strength and needs, risk factors, accommodation needs, physical and mental health, relationships, social and leisure interests and the personal goals the service user wishes to achieve whilst staying at Kentish Road. The personal plans are written in the first person and detail the service users’ daily routine and how they wish to be supported. A daily and nighttime record is kept which reflects the out-come of the service users’ stay. The record is very descriptive and summarises the service users mood, activity, assistance
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 12 required and what they have eaten during their stay. Where agreed a daily record is provided for relatives and where applicable information regarding the service users health and welfare is shared with their place of occupation, education and day service facility. This demonstrates the service takes seriously the needs of the service users, and the importance of providing a consistent approach that as far as possible reflects the service users home life, and the need to ensure primary carers are fully involved and aware of the outcome of their relatives stay. An individual approach is adopted to meet the service users needs, however Kentish Road does not take the lead in developing person centred planning as the service is one element of the individual life, not the primary source of care and support. The manager is however advised to seek advice on how personal plans can be made accessible for service users with cognitive and sensory disabilities and how they can be involved in the development of their personal plans. The service undertakes risk assessments on service users in all aspects of their care and social activity. In addition the home undertakes a skills assessment to identify areas of need and risk to the service users such as using the stairs, responding to fire alarms, making drinks and snacks and managing their personal hygiene. The assessments identify how to minimise the risk and are completed in simple detail. This demonstrates that the service as far as feasibly possible considers and protects the service user from areas of risk to their health and welfare. However the manager must ensure all service users have risk assessments undertaken on them including those who have been placed as emergency placement with a view to moving on into residential care. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 17. The service does well to support service users in activities of their choice, both in the home and the community and provides healthy and well-balanced meals. EVIDENCE: Discussions with staff, cash receipts and service users’ personal plans provide evidence of activities that service users are regularly involved in whilst staying at Kentish Road. A service user who had opted to have a “lazy day” at the service rather than going out to a planned activity stated she liked staying at Kentish Road because she was supported to do what she wanted when she wanted. The service user was enjoying watching a selection of videos and having quality time with staff. Kentish Road offers a variety of in house activites from watching TV to playing individual and team games such as pool and football. The home has a large communal room that functions as a lounge, dining room and games room, which includes a full size pool table. Service users are welcome to bring in activities of their choice and maintain social links and activities that they would attend if at home. In addition when resources permit, the service will support service users to attend social and leisure activities such as going to the cinema, pub lunches and shopping.
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 14 Service users are encouraged to maintain attendance at occupational, educational and day service facilities whilst using Kentish Road, however as evidenced above service users do not have to attend if they do not wish to. The inspector observed the service user who had elected to stay at home regularly making drinks and snacks. The service user stated that food was very good and they could choose what they wanted to eat. The inspector was informed by staff that service users are assisted and supported to make choices about what they want to eat, when to eat and where to eat. A record is kept of what the service users have eaten. Assistance is provided where required and when there is a specific area of concern the service will seek support from appropriate professionals such as dietician, occupational and speech and language therapists. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 The service does well to support service users with their personal care in a way that they prefer and with their physical and emotional needs. EVIDENCE: Clear and detailed personal plans provide evidence that service users are supported with their personal care and daily activity in the way they prefer or they are used to. The manager informed the inspector that the service tries as far as feasibly possible to reflect the routine the service user is used to. The inspector was provided with an example of how the service prepares for a service user coming in for their stay. The staff with whom the inspector spoke with were able to clearly repeat the preparation process detailed in a service users personal plan. This demonstrates good communication skills and good practice in ensuring the service user is made at ease during their stay. This was also later demonstrated by staff when greeting a service user at the end of the day, every one was aware of their particular role and how to ensure the service user was warmly welcomed and supported to avoid an adverse reaction to his emotional and physical health. Kentish Road ensures service users’ physical and mental health needs are met, through discussion with staff, the manager and viewing personal plans the inspector established that service users are supported to attend primary health care appointments and the service works very closely with specialist health care teams and relatives in meeting specific areas of concern related to
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 16 individual service users such as communication, epilepsy, challenging behaviour, eating and drinking etc. The manager will arrange training for staff in these areas if applicable. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home does well to listen to service users and as far as feasibly possible protects them from potential abuse. EVIDENCE: The home has incorporated a complaints procedure in an accessible format in the Service User Guide which details whom the service user can speak to if they are unhappy and includes useful contact numbers such as advocacy services, social services and the Commission for Social Care Inspection. However the home is advised to change the name of the regulatory body from the National Care Standards Commission (NCSC) to the Commission for Social Care Inspection (CSCI). An oversight when the brochures were published. Until such time the title can be changed the manager is advised to place a sticker over the incorrect name and ensure service users and/or their representatives are made aware of the change. The service user who had remained home for the day was reluctant to hold a full conversation with the inspector however the service user did state that she was happy staying at Kentish Road and would speak with her keyworker if she was unhappy. The manager advised the inspector that the home ensures that all its staff are made aware of the Local Authorities Adult Protection procedures, “Protecting Vulnerable People” and receive abuse awareness training. This was confirmed by the staff with whom the inspector spoke with, both staff said they had received training and provided detail on what they would do if they suspected or witnessed an abusive act. In addition staff undertake diversity training, person centred planning, the house and corporate induction, Learning
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 18 Disability Award Framework and a National Vocational Qualification which all cover abuse awareness. The Local Authority has produced accessible leaflets, developed in an easy to read text for service users and staff. These can be produced in audio, large print and Braille if required. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29 and 30 The service provides a spacious, clean and well-equipped environment that promotes service users independence and individuality. However the home must ensure all facilities available to the service users are in a good state of repair and are clean. EVIDENCE: The service has recently undergone an extensive refurbishment, making improvements to its decoration, furnishings and accessibility for service users who have physical disabilities associated to their learning disability. Kentish Road is spacious, clean and tastefully decorated throughout. The service users have options to choose where they want to spend their time, the home has a large lounge/games rooms and three smaller lounges that each have a television, video/DVD player and comfortable seating. Alternatively service users can opt to use the room that has been allocated for their stay. All the rooms viewed by the inspector were found to be clean, tidy and personalised with the service users own belongings brought in by them for their stay. The home will as far as possible support service users to make a choice of bedroom for their stay and provide them with a key to the room if they wish. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 20 The home has refurbished two downstairs bedrooms with on suite bathroom and shower facilities to accommodate service users who require assistance to transfer and who require full support with their personal care. The home has ample bathing and toilet facilities, two kitchens and a separate laundry facility. On inspection of the bathrooms and the on suite shower facility the inspector found: 1.The en-suite shower basin was in need of thorough cleaning. 2. The basin to the upstairs shower basin was in need of replacing. 3. The toilet seat to the downstairs toilet was in need of replacing. The staff are responsible for the cleaning of the service, cleaning is undertaken when service users have left the service for the day. Bedrooms vacated after service users stay are thoroughly cleaned in preparation for other service users coming in. Clean bed linen and towels are provided. The manager informed the inspector that she had placed an advert for a part time cleaner to free up staff time to work with service users on their personal plans and allow time for training and supervision. The staff with whom the inspector spoke with said they didn’t mind cleaning and said they saw it as part of their role and responsibility in ensuring a quality service is provided for the service users. One member of staff said they enjoyed supporting service users to clean and tidy their rooms, which assists them to improve their daily living skills. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 and 36 The home does well to provide service users with well-trained, competent and supervised staff. The home does well to deploy staff to meet the needs and numbers of the service users, however the home must fill staff vacancies. EVIDENCE: The inspector met with two members of staff who have worked in the home for a short period of time. Both staff appeared confident and were observed to go about their duties competently. The interactions between the staff and service users and between colleagues were both professional and respectful. Both staff said they really enjoyed working at Kentish Road and stated it is a very supportive and relaxed service to work in. The staff informed the inspector that they had undergone a thorough induction process and regularly attend training such as moving and handling, first aid, fire and training specific to the needs of the service users such as managing challenging behaviour, epilepsy and communication. The staff are also supported to undertake the Learning Disability Award Framework and a National Vocational Qualification (NVQ) in care. The manager informed the inspector that the staff receive regular support and supervision to discuss their performance, training needs and the specific needs of the service user that they are keyworker to. The staff demonstrated that they have a good understanding of their roles and responsibilities and the philophoshy of the service. One member of staff said it was important to help the service users enjoy their stay and support them to maintain and develop their skills and provide opportunities for them to access
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 22 the community. Another member of staff said that it was very important to be a good listener, patient and make sure the service users are comfortable and that their needs are met. The manager informed the inspector that there had been some difficulty in filling 5 staff vacancies. The manager was able to provide evidence that attempts had been made to recruit staff to the home. The manager deploys staff appropriately to meet the need and numbers of service users, however the service is currently back filling gaps in the duty rota with their own staff. The staff with which the inspector spoke with said they didn’t mind doing the extra hours as this provided a consistency of care. This in part is seen as good practice however the manager is advised to monitor extra hours worked by staff to ensure they do not exceed unacceptable hours. To consistently work long hours is not healthy and can potentially have a detrimental affect on the service users. The manager informed the inspector as part of her recruitment drive she hoped to employ a part-time cleaner which will free up support staff to have more quality time with the service users. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The service does well to ensure fire procedures and fire records are regularly undertaken and kept. However the service would do better to install an appropriate device on fire doors to assist service users to open them and leave open if they wish. EVIDENCE: The inspector viewed fire records, which demonstrates that the service undertakes regular checks on the homes fire system, in addition the services fire systems are regularly checked by outside contractors and Southampton City’s Council Maintenance department. The manager informed the inspector and further evidence was found in service users personal plans that each service user is individually risked assessed on their ability to respond to the fire alarm and undertake an evacuation. This is seen as very good practice. The service is fitted and equipped with appropriate fire fighting equipment throughout, however the inspector observed that bedroom doors are heavy and have no mechanism for remaining safely open. It was reported by the
32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 24 manager to cause difficulty to some service users and some service users do not like to have their door shut, something they are used to whilst at home. The manager is advised to seek advice from Hampshire Fire and Rescue Service on an appropriate mechanism to hold fire doors open and assist service users to easily open their bedroom doors. 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 X X 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 X 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
32 Kentish Road Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000039603.V249992.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation Requirement Timescale for action 30/11/05 13(4)(a)(b)(c) The registered manager must ensure the service user identified at the time of the visit is risked assessed in all areas of their health and welfare needs. This is especially important, as the service user will be moving into residential care. The registered manager must replace the shower basin situated in the upstairs bathroom. The registered manager must ensure all bathing facilities are left thoroughly clean after use. The registered manager must seek advice from Hampshire Fire and Rescue Service on an appropriate mechanism for holding open bedroom fire doors. 2 YA24YA25 23 31/01/06 3 YA24YA25 23 30/11/05 4 YA42 23(4) 31/01/06 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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 Refer to Standard YA5 Good Practice Recommendations The registered manager is advised to develop the service users statement of terms and conditions and charter of rights in an accessible format. The registered manager is advised to seek advice on how the service users personal plans can be developed in an accessible format to meet the needs of service users with cognitive and sensory disabilities. The registered manager is advised to monitor staff hours to ensure staff are not exceeding inappropriate hours of work. 2 YA6 3 YA33 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 32 Kentish Road DS0000039603.V249992.R01.S.doc Version 5.0 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!
