Inspection on 14/08/06 for 34 Lancaster Gardens

This inspection was carried out on 14th August 2006.

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

Other inspections for this house

34 Lancaster Gardens 09/03/06

34 Lancaster Gardens 01/11/04

34 Lancaster Gardens 28/06/04

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 34 Lancaster Gardens 34 Lancaster Gardens Herne Bay Kent CT6 6PU Lead Inspector Julie Sumner Unannounced Inspection 14th August 2006 1:30 34 Lancaster Gardens DS0000023297.V301278.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 34 Lancaster Gardens DS0000023297.V301278.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. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 34 Lancaster Gardens Address 34 Lancaster Gardens Herne Bay Kent CT6 6PU 01227 368915 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) sharon.fch4@virgin.net fchltd.headoffice@virgin.net Family Care Homes Limited Mr Scott Thompson Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: 34 Lancaster Gardens is a detached house situated in a quiet residential area of Herne Bay and is owned by the private company ‘Family Care Homes Ltd’. The home is registered to provide personal care and support to up to 7 adults with learning disabilities between 18 to 65 years of age. The service focuses on developing social skills, providing support with communication difficulties and providing positive behaviour support for people who have learnt to behave in a way that limits their lifestyle opportunities. The current fees for the service at the time of the visit range from £480.29 to £971.00. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The provider web address is included in the previous page with other contact details. All rooms are for single occupancy and have a wash hand basin unless this is not required. One room has en suite facilities. There are 2 bathrooms. There are 2 lounges and a separate dining room. There is a garden to the front with plenty of off street parking at the front. The garden to the rear has seating including a swing seat. The laundry facilities are external and there is a small summer house where some of the administration is carried out. The home is decorated and furnished in a style that suits the people living in the home and effort is made to provide a homely environment in consideration to safety and some individuals preference for minimal belongings. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The inspector visited the home twice to talk to service users, the manager and staff and view records and practices. The time spent in the home overall was 9½ hours. Information was gathered for this inspection by a variety of means both prior to and during the visits to the home. The CSCI request information from the home routinely and the home manager provided all the information requested in the pre-inspection questionnaire prior to the inspection visit. Comment cards were sent before the inspection visit, to the people living in 34 Lancaster Gardens (service users), relatives, health care professionals, care managers and GPs. Completed comments cards were received from service users and visiting professionals. “Relatives said: “we are really happy with the home”, ”this is the best home he has lived in”. Visiting professionals said: “behaviour is well managed and clients are making good progress.” If insufficient time has been allowed for all responses to be included in this report then they will be held on file and included in the annual review of the home. Service users (who were able to and wished to) spoke individually and in private about the things they do and what they like about the home. Service users made mostly positive comments including: “I like it here”, “Like my room”, “staff are nice”, “like going out, go with staff”, and talked about aspects of their lives that are current. The following methods of inspection and information gathering were used in the home: observing activity in the home, spending time and talking with service users and staff, both individually and in a group, looking at the building and touring the home, reading and discussing policies, plans and records including individual service user plans, medication storage and administration, some staff records including induction training programme and training records and other certificates and records in the home. All key standards were assessed at this inspection. 5 out of 7 requirements made at the previous inspection have been met. 2 requirements made that are ongoing have been given extended timescales for completion. 2 requirements and 3 recommendations were made as a result of this inspection. What the service does well: 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 6 The staff team work hard to provide different communication methods and work with other professionals to support individuals to express themselves. Opportunities and safeguards are also put into place with advice from other professionals to provide a secure, safe environment. The aim is to enable service users to develop skills to overcome behaviour that challenges and widen lifestyle choices. The home is clean and is organised with service users’ preferences and needs in mind. Bedrooms are personalised, again, dependent on individual preferences. The front lounge looks homely with good quality, comfortable furniture and a new cinema screen T.V. There is a good complement of staff working different shifts to accommodate service users’ lifestyles. A good range of training is provided to give staff the skills and confidence to support individuals effectively. What has improved since the last inspection? What they could do better: 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 7 All service users need to have a contract that outlines what the service provides and the fees. A requirement has been made for this. The laundry falls short of the National Minimum Standard. The laundry is currently housed in an out building that is unsuitable. A requirement from the previous inspection has been carried over. The quality assurance system needs to be developed further. A development plan needs to be designed for the home outlining how the service is going to improve and based on the views of service users and their advocates. A requirement has been made for this. The statement of purpose and service user guides need to be reviewed to include expectations around freedom, door keys etc and the aims of the service with regard to protecting individuals and minimising destructive/ challenging behaviour. A requirement has been made for this. 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. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guides need to be more informative about what the home actually provides. Service users can be confident that their needs have been assessed and that any aspirations have been included as appropriate. New service users can expect a contract with clear information outlining what the home provides and the fees. Existing service users’ contracts need to be reviewed and they/their advocates would benefit from the new design. EVIDENCE: The statement of purpose and service user guides need to be reviewed to include the outcomes of environment risk assessments with regard to restrictions on freedom to safeguard service users. Please refer to standard 16 and 24. A requirement has been made for this. The new assessment formats were discussed with the registered manager. Service users spoken to by the inspector focused on what they want and what is happening immediately or in the next few days and seemed unclear about what they want beyond that or the concept of future. Staff have spent time with service users to ascertain their personal aspirations and have had different responses depending on each individuals understanding. The new 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 10 assessment format has been designed with a section to record personal aspirations. A sample of person centred plan assessments were viewed and also discussed. These vary from individual to individual as intended and were focused on what is important to each person and using whatever style they are most comfortable with including: photos, pictures, simple references, who is important, communication, displays of challenging. At present this assessment is being carried out with current service users as part of the change to person centred documentation. The home have had no new admissions since the last inspection. It is anticipated that this assessment is started when service uses first move in the home and carried out over a period of time as part of the process of getting to know individuals. Contracts are not kept in the service user plan folders and were not viewed at this time. A discussion was held with the registered manager about the contracts. The company has produced a new format for contracts in line with NMS and all new admissions will be given this contract. No new service users have moved into the home recently and ,therefore current service users, have the old style contract which is kept at head office and includes the individual fees. Existing contracts are being reviewed to the new format on a company roll out programme. A recommendation has been made to make sure all service users have a contract that meets NMS. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 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, 7, 9 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 current good practice and their practice promotes individuals to develop their skills, including for some service users, independent living skills. Service users know their changing needs will be recognised and supported. Service users know they will be supported to take risks. EVIDENCE: Each service user has an individual service user plan. This is currently organised into different files. Most service users have 2 files each containing their service user plan. One file is recorded onto a corporate format, is needs lead and currently contains annual reviews, risk assessments and reviews, behaviour guidelines and property lists/receipts etc. The second file is called a ‘Key worker’ file and is more person centred and produced in an accessible format for service users with photographs etc and keyworker reports of days out. Further files contain archived daily record information and other 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 12 miscellaneous records. The Key worker file focuses on what is important to the person and this evidences that the staff supporting service users do view them individually and respect what is important to them. The manager has begun the process of redesigning the service user plans. Two service users have newly designed folders with pictures, photos and large print. These focus on individual wishes, who is important to them, what is important and how they would prefer to be supported, and also includes likes and dislikes. A third file was in the process of being developed with the service user at the time of this inspection. Risk assessments are included in the corporate file with strategies recorded to reduce risks. There was a discussion with the manager about using the person centred format as the main point of reference for meeting individual needs and having all necessary information in this including risk assessments and guidelines for staff to meet needs on a daily basis, so that this becomes the service user plan rather than being an add on. A recommendation has been made to continue the redesign of the service user plan to be focused on what is important to each individual. A further recommendation has been made to organise the records that have to be kept in the home so that they are accessible for when needed but do not necessarily have to form part of the redesigned service user plan. 34 Lancaster Gardens DS0000023297.V301278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling service users to develop their skills, including social, emotional, communication, and independent living skills. Help with communication skills is given by staff to assist with pursuing interesting activities both in the home and in the community. Service users have the opportunity to maintain important personal and family relationships. Policies, procedures and guidance promote individual independence and restrictions to freedom put in place have been considered within a risk assessed framework. The food in the home is of good quality. Opportunities are available for service users to be involved in food shopping, the preparation of meals and menu planning. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users access a range of leisure facilities. There is an overall activity plan which gives a basis to the structure of the day but is flexible and is actioned depending on individual choice. There were individual activity planners in service users files. Risk assessments have been carried out and guidelines have been written for taking service users out of premises. A relative visited and completed a form prior to going. Service users, who were able to, spoke about their hobbies, like playing golf, going out for meals, to the pub and creative activities and showed the inspector some of the crafts made the day before. One service user said they were going out for a meal today. Staff explained how they support individuals with occupational and day-to-day activities and various charts and boards were viewed. Communication notice boards are on the wall in the hall to assist service users in knowing what tasks need to be completed and what events are happening so that they can make an informed choice throughout the day. For one individual photos are stuck on board and when the task/activity is completed then the photo is removed from the board and put in a box ready for next time. All service users were going out at some time during the day. One service user went out for a walk in the afternoon having requested to. The home has two Galaxy people carriers unfortunately they both broke down when out. Have just had one repaired. Have recovery service so were able to get back safely but affected the activity. Director considering replacement after events of today. One service user spoke about their family and said they were visiting and going out that day. Family contact details were in each service user plan. The newly designed person centred plans had family members included as people who are important to individuals. There were records of contact made. Individual risk assessments have been carried out with regard to keys to access the home, bedrooms and restrictions imposed including the locked bottom half of the stable style door to restrict access into the kitchen. Risk assessments have indicated that some restrictions are necessary to protect individuals. A discussion was held with the manager about the service provided in the home and that the people assessed as needing this kind of environment did need these kinds of restrictions. If they did not need this then the home would be considered unsuitable. It was agreed that the statement of purpose 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 15 and service users guides should state this so that it is clear who the home is intended for and what the home provides. A requirement has been made to review the statement of purpose and service user guides to reflect what is provided, the restrictions to freedom and how this is reviewed. Service users spoke to the inspector about the meals and all were happy with what is provided. One service user said they like cooking and their activity records indicated that this activity is offered and appropriate risk assessments are in place. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their wishes and preferences will be taken into account in how they are supported. Service users benefit from good health care support and are able to access community health care services. Medication procedures have improved and medication is stored and administered correctly and safely. EVIDENCE: The person centred plan that is gradually replacing the existing care planning system provides information on individual preferences and wishes. The key workers have got to know individuals and make sure that the other staff are kept up to date with what individuals want and any changes by recording key worker reports and discussions. Service user meetings are held at least every other month. A sample of minutes were viewed. Some service users are able to say, clearly what they want and others need assistance with communication. Communication aids including photo boards and wallets have been designed and the speech and language therapist is involved with those who need it. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 17 New health assessments have been designed and a sample were viewed. Information in them is useful and up to date and service users and staff are developing them as an ongoing plan and record. One of the staff was observed administering medication. Medication storage was also viewed. A medication trolley has been purchased and is kept in a locked cupboard in the main building. The home uses the Boots monitored dosage system. Improvements have been made to both administration and storage since the last inspection. The registered manager conducts a monthly audit and no errors have been reported and none were noted at this inspection. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective complaints process. Service users feel they are able to discuss issues and are listened to. Service users are protected from harm by the policies and procedures in the home. Staff are knowledgeable about adult protection. EVIDENCE: There is a complaints procedure in place. Service users spoke to the inspector and said they know what to do if they have a complaint. Service users indicated in the surveys that they are aware of how to complain. A sample of records was viewed. Service user meetings are held monthly and minutes taken. Staff get to know individuals with communication difficulties and respond to signs, behaviour and facial expressions to gain understanding of what is being communicated to them. Pictures and symbols are used around the home and some service users communicate using objects of reference. Discussed whistle blowing policy and adult protection procedures with the registered manager. All staff have attended adult protection training and demonstrated an awareness and knowledge during conversation. 34 Lancaster Gardens DS0000023297.V301278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is as homely as service users will accept and is changeable depending on service users’ needs and preferences. Service users are happy with their bedrooms, which are personalised. The laundry facilities fall short of the minimum standard required. EVIDENCE: A tour of the home was carried out with one of the staff and the inspector was introduced to service users and staff. The manager has reviewed the overall environment. There is an action plan to make all necessary maintenance improvements. A maintenance person is employed in the home two days a week routinely to make ongoing repairs to the building. A service user talked to the inspector about the building and has a particular eye for repairs that may be needed and assists the maintenance person to record what needs to be done. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 20 Service users showed the inspector their bedrooms. All bedrooms are personalised and reflect individual interests. There were generally quite minimal in décor and furniture but each bedroom was different and each person had the amount of furniture and ornaments that they could manage. Staff have worked hard to make sure that service users are safe, that damage to property is limited by good management and that the environment is regularly reviewed. Items of furniture, pictures and belongings have been introduced gradually to make it more homely. A cinema screen TV was purchased by one of the families and is situated in the front lounge. Service users have looked after this and were enjoying watching it at various times throughout the visit. Service users dignity and privacy has been respected by providing alternatives to curtains when these have not been tolerated. This is also reviewed and there are different window coverings depending on individual need. One service user has curtains in their bedroom after support and management of destructive behaviour. Staff have the use of 2 company vehicles which they use to access community facilities and amenities. The home was clean throughout. The home has been carpeted in the past but these were removed and replaced with various types of washable flooring which does add to the starkness but is currently necessary to keep the home clean and odour free. This is also part of the environmental risk assessment. The laundry is situated in an out building and was viewed. An asbestos assessment has been carried out. Guidelines from the risk assessment were on display for health and safety. The company has purchased a new tumble drier. All equipment was in good working order. The laundry building needs improvements, as it does not fully meet NMS mainly because it does not have flooring that could be washable and sufficient hand washing facilities and surfaces to maintain a hygienic facility. The company have drawn up plans for a new laundry building that will meet NMS. A requirement has been made to complete this. 34 Lancaster Gardens DS0000023297.V301278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The NVQ training programme is underway. A good range of training is provided to meet individually assessed needs. There are robust recruitment processes in place protecting service users. Service users benefit from an enthusiastic and supportive staff team. EVIDENCE: The registered manager holds NVQ 4 and RMA and is currently studying to be NVQ assessor. There are 15 staff in the team. 2 staff have NVQ 2 and 2 staff have NVQ 3. The home has reached the target before but with staff changes this is under the 50 at present. 2 staff are currently studying NVQ 2 and 3 staff are studying NVQ 3. A recommendation has been made to continue with the NVQ programme to, once again, reach the workforce target. No new staff have been employed since the recruitment procedure has been reviewed. The registered manager explained the circumstances of the omission leading to requirement at previous inspection and confirmed that no staff would be allowed to start work without appropriate references. 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 22 The induction training package has been redesigned in line with “Skills for Care”. The content of this was viewed. Staff training is ongoing. The company training department provides sufficient training for all staff. All mandatory training is up to date. Three staff were attending autism training on the first site visit. A sample of certificates of varied training carried out by different staff were viewed that are kept in a folder. 34 Lancaster Gardens DS0000023297.V301278.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 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 a home that is well managed within clear parameters. The quality assurance monitoring system needs to be further developed with feedback sought from a wider group and used as a basis for the design of a development plan for the home. The home’s practices ensure the health and safety of service users and staff. Some policies have been reviewed, usually when issues have arisen. All others need to be reviewed proactively. The home has a good record of meeting health and safety requirements. EVIDENCE: 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 24 The registered manager has developed and improved parts of the service since the last inspection. All requirements and recommendations made at the previous inspection that are within the registered manager’s control have been met or are in the process. A service review including an environmental assessment has been carried out by the registered manager in the last month. It was not possible to view this report at this inspection but the manager described some of the contents. The home has some quality monitoring in place. Feedback from service users and relatives is sought both verbally and using questionnaires. Key workers talk to service users about what they want and write a monthly report also feeding back to the manager and advocating for individuals if needed. Service user meetings are held monthly. A sample of minutes were viewed. Regulation 26 visits are carried out monthly and reports are given to CSCI. At present the company produces overall business plans for all homes including priorities for improvement. An individual report has not been produced for the home to bring the outcomes of quality monitoring together for 34 Lancaster Gardens. A development plan needs to be designed for this home so that everyone is working towards improvement of the home and the service provided to service users. A requirement in relation to this has been carried over from the previous inspection and the need to design a development plan has been added to it. The Pre-inspection questionnaire (PIQ) indicates that policies have been developed/reviewed in 2003. A policy folder was accessible in the home. The home’s policies have been reviewed as needed, some of which have been in response to situations occurring or from the inspections and are included elsewhere in this report. An overall review needs to be made on all existing policies to make sure they are relevant and workable to assist staff in how to respond in specific situations. Current policies need to be checked against NMS appendix 2 to make sure all are in place as there were some gaps in the PIQ. A recommendation has been made to make sure all policies are up to date and workable. Mandatory training is ongoing and all staff have completed relevant training to support the needs of service users living in 34 Lancaster Gardens. A sample of records and maintenance certificates were viewed. The home has a maintenance person allocated who was on site during the inspection. The environment has been modified to protect service users and staff and provide a safe place to live and work. Risk assessments have been carried out. Appropriately styled doors, windows and fencing have been fitted securely to provide good security to service users. 34 Lancaster Gardens DS0000023297.V301278.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 x 4 x 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 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 2 x 3 x 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 6 (a)(b) Requirement The statement of purpose and service user guides need to state clearly what the service provides with regard to restrictions to freedom to support service users and how this is reviewed. Contract/Terms and conditions needs to include the fees charged what they cover and charges made by the company for any extras. Information needs to be incorporated about when fees are payed and by whom. The laundry must be in line with the minimum standard. (Previous timescale 31/07/06 not met.) Revised timescale refers to proposed building action plan. Timescale for action 30/11/06 2. YA5 5 (b)(c) 30/11/06 3. YA30 13 31/10/06 4. YA39 24 The service must be reviewed at 30/11/06 appropriate intervals in consultation with service users and a report produced. (The previous timescale for this 31/07/06 was not met.) A development plan needs to made from the report outlining future plans to improve the service and DS0000023297.V301278.R01.S.doc Version 5.2 Page 27 34 Lancaster Gardens how this is going to be implemented. Once produced a copy needs to be kept in the home and a copy to CSCI to meet this requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations To continue the redesign of the service user plan to be focused on what is important to each individual. To use the person centred format as the main point of reference for meeting individual needs. To organise records that have to be kept in the home and not necessarily have them in the service user plan if they are not important to the individual and are not useful for staff to assist with day-to-day support. (ref Schedule 3) To continue with the NVQ programme to, once again, reach the workforce target. To make sure all the home’s policies are up to date and workable. 2. YA6 3. 4. YA32 YA40 34 Lancaster Gardens DS0000023297.V301278.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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