Inspection on 30/01/07 for 32 Kentish Road

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32 Kentish Road 08/05/07

32 Kentish Road 13/01/06

32 Kentish Road 29/09/05

32 Kentish Road 28/02/05

32 Kentish Road 03/01/05

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Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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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 32 Kentish Road Freemantle Southampton Hampshire SO15 3GX Lead Inspector Clare Hall Unannounced Inspection 30th January 2007 10:30 32 Kentish Road DS0000039603.V322806.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 32 Kentish Road DS0000039603.V322806.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. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 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.V322806.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 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. The client contribution for an overnight stay is approximately £3.56. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit to Kentish Road place on 20th January 2007 and was undertaken by one inspector over one day. Throughout the visit the manager was available and the staff assisted the inspector in general. The judgements made in this report were made from information gathered pre-inspection from previous reports, the service history, Regulation 37 notices received and reports sent to the CSCI by the provider. Also considered were correspondence with the home, contact sheets, reports and feedback relayed to the commission by staff, family members and service users. The areas of any concerns raised and evidence gathered which have informed the judgements were discussed with the manager at the end of the visit. The manager assisted the audit process by handing out relevant comment cards to service users other stake holder’s, health and social care professionals and staff. The management team completed the pre inspection evidence and this was used to inform the inspection process and report. The environment was audited and a tour of the premises undertaken. The inspector had the opportunity to visit the nearby day centre where service users undertaking respite at Kentish Road were during the day. As a result of this audit 8 requirements have been raised. What the service does well: Service users and relatives reported they are kept informed. The transition into the home is carefully managed and undertaken so to ensure it is the right place for those who wish to stay. It is firmly led by whether it have a positive outcome for each individual. All service users and their families were complimentary regarding the service Provision by Kentish Road. The service users felt safe and secure and spoke highly of the staff. Service users benefit from support to attend day centres, socialise and participate in activities through choice. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 6 Their stay is driven by consultation and their preferences respected. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 32 Kentish Road DS0000039603.V322806.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 32 Kentish Road DS0000039603.V322806.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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives reported they are kept informed. The transition into the home is carefully managed and undertaken so to ensure it is the right place for those who wish to stay. It is firmly led by whether it will have a positive outcome for each individual. Record held do not identify whether all residents have agreed with the terms of stay. EVIDENCE: The residents stated they visit the home and can stay for tea before they decide if they wish to go to Kentish Road. Records supported this and identified that a thorough and detailed process is undertaken to ensure the service meets the expectations of both the client and their family. This transition can be quite long and detailed, involving care manager and significant persons in each of the prospective clients life. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 9 The manager discussed a visit made that morning to a family and the depths taken to also reassure and support the family about their son/daughter undertaking a period of respite. All relatives reported that the home and staff kept them informed of important matters. Comments received by one relative was, “I’m always happy to go to Kentish Rd. We feel she is looked after very well”. During discussion with staff they explained how important it was to fulfil peoples expectations and help them to feel safe and secure and a part of the decision making process of whether to come to Kentish Road. The services service guide is formatted to suit the needs of residents but requires some updating. Fewer than 50 of relatives knew of the home’s complaints process when asked. All eleven stated they had not seen an inspection report regarding the service. Not all residents’ files have signed and dated terms of stay. It was acknowledged that the CSCI surveys are not fully suited to the needs of all individuals and therefore responses may not be a true reflection of the service. Service users do not always understand the term complaint and would be happier to use simpler terms such as whether they are happy or not. 32 Kentish Road DS0000039603.V322806.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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are aware of the assessed needs of individuals and observation would indicate needs were being met and expectations fulfilled. The recording of the individual’s psychological, mental health and emotional needs are not fully recorded in respect of the support they require. The current assessment and recording of needs is very staff orientated and could be developed so to empower the individual by use of alternative formats, signs and pictures. EVIDENCE: Comments received by the service in view of a recent survey included, “ My son always enjoys his stays and wouldn’t want to go anywhere else.” “They have choice and support.” 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 11 Overall the survey identified that most people agreed the service gave residents choices and opportunities to do things they like. All relatives surveyed stated categorically that if their child was not able to make decision that they are consulted about their care. The current clients were case tracked and during discussion with one client in the day care service and then later at the home it was identified that she had lost a number of significant people in her life recently. Her care plan addressed her needs in consideration to her social and physical abilities but not with respect to her psychological and mental health needs and issues of bereavement and or separation. The other care records were descriptive, detailed and reflective of the needs of individuals on the whole. The plans could now be developed into a more service user-friendly format and identify that the individual has driven the plans. Rather than “X needs” the records could record what the individual sees as their needs. i.e. “I need…” or “I like”. With the help of their day centre key workers, service users reported what they thought of Kentish Rd and said, • • Yes I like it because my friend are there too sometimes, We all try to talk about choices with other people staying to make it fair for everyone. This is good. Staff surveys reported comments stating, Kentish Road provides choice, independence and treats all service users as individuals. It gives a valuable service to service users and carers. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from support to attend day centres, socialise and participate in activities through choice. Their stay is driven by consultation and their preferences respected. Consideration is required regarding the support of individual’s sexuality and forming close bonds and relationships. EVIDENCE: All relatives responding to the CSCI survey stated that staff welcomed them into the home at any time and that they could visit their friend/relative in private. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 13 Three service users were visited at the day centre and discussion held regarding their stays at Kentish Road. All feedback was positive, Service users smiled and stated how much fun they had and how nice the staff were at Kentish Road. Service users explained how they could go shopping, go out whether swimming or undertake other activities such as meals out and visits to the pub. Two service users were noted to be particularly close and the manager was asked whether the home had any directives guidance or policies in respect of supporting people in their sexuality and when developing relationships. It was reported that the home does not have any policies regarding this. When speaking with service users it was identified that it is their choice whether they participate in daily living and housekeeping tasks such as cleaning, shopping and cooking. Records indicate this is done within a risk assessment framework. The process in the home regarding mealtimes is that the residents are asked on a daily basis what they would like to eat and this is provided. There are no fixed menus and the process is completely flexible. One service user told the inspector he liked salad, which they provided. A bowl of fresh fruit and a large selection of foods were seen available. All food supplies were accessible. Record seen indicate the food provision is driven by the service users choices. It was noted that pie and chips were served quite often but as the resident stays were short this would not directly affect the health of the individual. Consideration would need to be made for any resident who may stay for an extended period of time. They would need some support regarding health education for nutrition. Service users supported by their day centre key workers reported that, • • • • • • • • It’s a good place, the staff take us out. Its good. I look forward to staying there. The staff do lots of fun things. they take me out to different places. I get to play music. I go out shopping with the staff, they’re all right. We get to choose our dinners. I sometimes watch TV and I can watch what I like. We have a laugh here the staff are fun. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 14 • • I like staying at Kentish road and I like making the choices as to what we have for tea. Its good as they do lots of cooking and I enjoy the meals there. 32 Kentish Road DS0000039603.V322806.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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care provision is undertaken through choice and consultation with individuals. The staff do need training in administering eye drops if this skill is required when supporting certain individuals. The home is in need of guidance in respect of supporting an individual’s end of life or sudden death. EVIDENCE: Care plans identify the needs of individuals in respect of their health and personal care needs and address ability /disability. Further work in respect of identifying the emotional needs of individuals has been discussed previously in the report. The manager acknowledged that work is still needed to ensure staff are competent in administering eye drops. The service does accommodate two service users who need eye drops and staff will need to ensure they have the 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 16 training before these clients are accommodated again or arrange for the community nursing team to support their stay. Medication administration records are completed and the new records allow for any omissions to be recorded. The manager has also written a policy addressing as required medication, which was read. Southampton City Council is currently reviewing their organisational medication policy. The manager explained that once it was drafted it would be adapted to suit the needs of individual receiving care within the learning disabilities services. The home does not have any policies regarding death and dying or end of life pathways. As this is not a common occurrence the manager has been asked to develop a policy regarding sudden death. 32 Kentish Road DS0000039603.V322806.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 in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are aware of how to protect vulnerable persons. Relatives are not 100 sure how to report a concern /complaint. EVIDENCE: The homes in house survey identified that when the significant people involved in the resident’s lives were asked whether they felt residents were well cared for reported, • • • Their family member was very well cared for, no problems at all” They always understand my son’s needs and that’s a first Always happy to go to Kentish RD. On the whole the majority stated they agreed or strongly agreed their son or daughter was being cared for. It was noted that some felt more encouragement may be needed but on the whole they were happy with the support provided. Only 50 of relatives surveyed stated they knew what the homes complaints procedure was. The manager discussed the handling and protection issues in relation to one individual. These were within local protection guidance procedures. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 18 Staff reported in their surveys how they would support vulnerable individuals wishing to make a complaint and what they would do if they witnessed poor practice. All responses were appropriate. One stated the following, “I would report it to the manager but if the manager was involved then I would report it to the line manager if it involved a member of staff and a service user then I would follow the protection of vulnerable adults policy”. Records indicate staff receive protection of vulnerable adults training. With the support of their key workers service users attending respite services at Kentish Road said, • • • I know to talk to staff. I think its Nicky who’s in charge so I’d talk to her. The staff like Nikki The staff always talk and listen to me. It was identified with support staff that the questions in the CSCI survey posed to the service users used the word “complaints” and this was difficult for service users to understand. Service users support workers stated the question needed to be in a more service user friendly format asking who would they tell if they were unhappy. The feedback in the survey indicated residents did not know what the homes complaints procedure but were confident that if they were unhappy they could/would tell certain individuals. 32 Kentish Road DS0000039603.V322806.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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment suits and supports the individuals accommodated. EVIDENCE: It was reported in the homes quality assurance surveys that the majority of the significant persons involved in the residents life agreed the home is clean and homely place while others felt they couldn’t comment, as they had not been there for some time. Resident’s feedback indicates they are happy with the cleanliness of the home and that the environment has improved significantly. Some further comments received by the establishment recently were “Kentish road service has always been brilliant and the refurbishments have made my daughters stay at Kentish road even more enjoyable” 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 20 A tour of the premises was undertaken and the home was found to be bright, airy, clean and well maintained. The accommodation is suitably adapted and supports the individuals receiving respite. One service users kindly took the inspector to her room and showed her how it had been personalised. She had a key and was proud of her “own room”. General comments and feedback received by service users supported by their day care key workers in respect of the accommodation was, “Nice rooms, new staff let me help around the house.” “It has nice bedrooms & recently been transformed. ”(care workers translation) Further comments were: “ It’s new now, but was a bit grubby before. “It’s better now, we’ve got new keys for the doors.” “The rooms are tidy. The staff help us put all our clothes away and support us with the shower.” It was reported that Southampton City Council are proposing to move the cities adult placement scheme /department into the home. It will use the rooms currently unused in the west wing of the building. The manager and inspector discussed this and how the service users current accommodation cannot be used as a thoroughfare for adult placement staff and visitors. Separate access would need to be considered and a clearly defined area where the service would not intrude on impact on the service provision, accommodation, communal space and safety of individuals accommodated. 32 Kentish Road DS0000039603.V322806.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): 32,33,34,35,36, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are empowered by the induction, training and supervision they receive and therefore have the skills to support their residents. The manager could develop a better audit trail of this and access to the supporting records. EVIDENCE: The majority of relatives asked felt there were sufficient numbers of staff on duty. Two relatives stated, “ I have always found the staff at Kentish Road very helpful,” and one stated further, “My son is well looked after there.” All staff surveyed reported they had all the necessary checks undertaken prior to employments and were regularly supervised. They also confirmed they were provided with an induction regarding their role in this service. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 22 It was raised with the manager that the records identifying that staff have received supervision and induction needs further development, as the records are not easily audited. All staff surveyed reported they received job descriptions and terms and conditions regarding their employment. Surveys further indicated that staff have received training in First Aid, Appraisal Training, NVQ 4, Moving and Handling and Fire Training, NVQIII Visual Impairment Awareness and Team Teach. Staff also commented that, “I have worked at Kentish Rd for over 5 years and enjoy it very much we have an excellent team and a super manager who I have learn lots from. She is always there for staff and service users alike. I feel I have plenty of opportunity to use and develop my skills and have been given all the support I have needed.” “Kentish Rd has good team work and a friendly atmosphere.” and “It’s a very relaxed environment for people to stay in”. One staff member reported that the things the home does well is the high standard of care the clients are given and the time spent with them, ” but she felt there was a lot of,”Red Tape”. Another staff member said, “The transition work from children’s services to adult services is done well by the home because we always have lots of information to enable the move to go smoothly.” 32 Kentish Road DS0000039603.V322806.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, 41, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by competent staff. Care staff ensure that service users are safe and secure. The organisations maintenance department needs to communicate effectively with the homes manager when there are issues, which might directly affect the safety and well being of the service users. EVIDENCE: It was also reported in the homes quality assurance surveys that the majority of the significant persons involved in the residents life felt, the service at Kentish Road is much better than the care offered at other respite services. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 24 Comments received included, “I think the service at Kentish road has improved since it re-opened in May 2005.” A 100 of those relatives asked felt they were satisfied with the overall care provided. One comment stated, “We are very happy with the standard of care. The most important thing is that our son is happy at Kentish Road.” Discussions with the manager and her team identified the staff are very committed to providing an excellent service. They have an excellent value base and thrive to ensure the service users needs are met. The staff were observed interacting with service users and discussing issues and concerns. They are supportive and sensitive whilst remaining respectful. Residents are treated as valued individuals who have clear choices and are supported as such. The care philosophy discussed indicates that a high consideration is for the service user to feel safe and secure and staff work as a team to promote these core values. The staff and relatives feel there is good supportive leadership in the home, and service users elicit smiles when talking about the manager by name. They refer to her and other staff with positive statements. The home was found to have excessive water temperatures during the visit. It was established that the maintenance department were aware and reported a fault on the system on 16/12/07 but did not reduce the boiler temperature despite raising it on the fault report sheet that there was a significant risk of scalding at some outlets. Immediately after it was identified with the manager called a member of the maintenance team to urgently address the excessive water temperature. The water was then rechecked and found in the kitchen to be in excess of 65 decrees c. This poses a significant burns risk to individuals as all service users have free access to the kitchen. As far back as February 2006 the water temperatures were being recorded in some areas as 70 degrees. On the maintenance record it was also identified that there were excessive temperatures reported in a bathroom. It was unclear what actions had been taken in respect of finding these excessive temperatures by the organisations maintenance department. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 25 It was established that the fault record is not copied to the manager and therefore the manager is not formally informed of faults when they are found. The manager did address this as a serious concern and had a risk assessment in place prior to the inspector leaving. She had also ensured staff were on site to reduce boiler temperatures. The manager has undertaken an internal satisfaction survey and analysed the outcomes. It was agreed this could now be developed further so to encompass the service users and other stakeholder’s opinions for the service provision. It was noted when looking for relevant supporting policies for care some of the homes policies are exceptionally old and do not reflect up to date practices regarding recent legislation. Policies and procedures also lacked review dates. Some information regarding good practice went back to 1988. The role of the key worker was dated 2004,The homes recording of information and access to records was dated 1st July 1991 and 1988.The homes statement of purpose was also out of date and was not a reflection of the current service. Maintenance records referred to the home under a different name. It was established that the home does not have a policy in respect of restraint despite service users using lap straps. Despite a change in the fire authority legislation, October 2006, the homes fire risk assessment has not been reviewed. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 26 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 4 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 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 2 x 3 3 3 2 3 2 3 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 27 yes 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 YA20 Regulation 13(2) Requirement The registered manager must ensure all staff responsible for administering medication is trained in the safe administration of eye drops. This has been raised previously and the compliance date of 31/03/06 has not been met. 2 YA5 5 The registered person must ensure all service users have agreed with the terms of stay and keep records to demonstrate this. The registered person must ensure that care records and assessments reflect the psychological and mental health, emotional needs of individuals. The registered person must develop guidance, which will support individuals who may wish to form close bonds and/or sexual relationships whilst ensuring they are safe and protected from harm. This will need to address capacity to DS0000039603.V322806.R01.S.doc Timescale for action 14/04/07 14/04/07 3 YA6 14,15 14/04/07 4 YA40 17 14/04/07 32 Kentish Road Version 5.2 Page 28 5 YA22 5 6 YA42 23,12 7 YA40 12 8 YA41 12,23 consent issues and risk assessment. The registered person must ensure that all service users and their representatives/relatives are informed and have access to a complaint procedure. The responsible person must ensure that the homes water is always delivered at a safe temperature. The registered person must ensure the home has relevant policies and procedures, which reflect current legislation and best, practice and reviewed. The home fire risk assessment needs reviewing in light of changing legislation. 14/04/07 14/02/07 14/04/07 14/04/07 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 3 Refer to Standard YA1 YA6 YA39 Good Practice Recommendations The manager is advised to ensure the service information is updated so that the correct information is given to service users and their relatives. The manager is advised to develop the care records so they reflect the individuals needs as they see them. The quality audit process could be expanded to audit all the standards within the home and reflect the opinions of all those who use the service including significant others. Care manager, medical health and social care professions and the service users. 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 32 Kentish Road DS0000039603.V322806.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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