Inspection on 11/08/08 for 351 Maidstone Road

This inspection was carried out on 11th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

351 Maidstone Road 03/10/07

351 Maidstone Road 31/05/06

351 Maidstone Road 16/12/05

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 351 Maidstone Road 351 Maidstone Road Wigmore Gillingham Kent ME8 0HU Lead Inspector Kim Rogers Unannounced Inspection 11th August 2008 10:00 351 Maidstone Road DS0000061864.V368922.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 351 Maidstone Road DS0000061864.V368922.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. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 351 Maidstone Road Address 351 Maidstone Road Wigmore Gillingham Kent ME8 0HU 01225 444596 01634 388513 maidstone.road@robinia.co.uk 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) The Robinia Care Group Ltd Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2007 Brief Description of the Service: 351 Maidstone Road (the Service) is registered to provide accommodation and personal care for up to seven people who have a learning disability. The house is detached with accommodation arranged on both the ground and the first floor. All of the bedrooms are for single occupancy. Most of them have a private wash hand basin, toilet and shower. There is parking to the front of the house and a large private garden to the rear. The premises are located in a residential area and are a mile or so from Rainham town centre. There is ready access to public transport. The Service has its own vehicle. The Registered Provider gives a variety of information to prospective people who might want to move in. The fee range for this service is about £1,900 to £2,200 per week. For more information the fee and services please contact the Provider. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key site visit took place on 11 August 2008 between 10.00am and 3.00pm and is part of the key inspection. The manager, service users and staff assisted with the process. The inspection process consisted of information collected before and during the visit to the home. Records were sampled including support plans, staff records, medication records and activity records. Some service users gave face-to-face feedback. One service user showed the inspector their room and other parts of the home. Organised and spontaneous activities were taking place throughout the visit, and observations formed part of the evidence collected. The inspector spoke to staff and the manager. The manager completed the AQAA (Annual Quality Assurance Assessment). This gives information about how the home has improved and how the home intends to improve. The AQAA gave some evidence of what the home does well and how they intend to improve although some parts were blank. The manager has been in post for just over a year but is leaving the home soon. Although the manager said he would address the shortfalls against Minimum Standards found at this inspection, a requirement was made to ensure the shortfalls are addressed after the manager leaves. Service users said that they feel safe and that staff are respectful. Service users it is good to have your own shower. Service users said it feels independent to have your own bedroom door key. The requirements made at the last inspection have been met. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. What the service does well: Service users bedrooms are personalised making it feel like home and most have en suite shower facilities. Some of the staff team are longstanding and know service users well. Recruitment checks are robust which protects service users. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 6 Staff induction and training is comprehensive and related to service users needs. This means that staff have the skills and competencies they need to support the people who use the service. The monitoring of people’s health is good with detailed observations and records kept. This means that any changes in need can be picked up and acted on quickly which helps keep people healthy. What has improved since the last inspection? What they could do better: The management of the home has been inconsistent for the past 3 years with 3 different managers. The present manager is leaving in a couple of weeks and as yet has had no handover with a new manager. All homes are required to complete an Annual Quality Assurance Assessment (AQAA) every year. Some parts of the AQAA relating to how they intend to improve were blank. This means that with no clear idea and plan about what needs to improve and how, outcomes for people may not improve. Service users experience some good outcomes. The challenge for the staff is to continue supporting people to grow and develop and live the lives they want. Each person needs a person centred plan to support his or her hopes and dreams for the future. Clear plans of support are needed to develop and increase people’s skills. The location of an office immediately by the front door does not contribute to the development of a normal domestic atmosphere in the home. This should be reviewed in consultation with service users. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 351 Maidstone Road DS0000061864.V368922.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 351 Maidstone Road DS0000061864.V368922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use the service experience good outcomes Information about the home is produced so people have help in making a decision about moving in. People know that their needs and future goals will be assessed to make sure the home can support them properly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is some written information about the home that is given to prospective service users. The manager said there are plans to improve this information so that it may be more meaningful to people. The manager said that no one has moved in since the last inspection. One person wants to move in and stays every now and again to get use to the home. The manager said he wants to ensure there is enough staff to meet the person’s needs before they move in. The company have improved the assessment tool used to establish people’s needs and aspirations. The AQAA says that they plan to improve by updating the information about the home and by developing person centred planning. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 10 351 Maidstone Road DS0000061864.V368922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience adequate outcomes Work and support is needed to develop and implement person centred planning to ensure people’s needs and goals are supported. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has two files, one with their support plans (or service user plan) and the other a daily working file with daily notes and monitoring records. Two people’s plans were sampled. We found that one person has no plan recorded. This means that staff may not be aware of the person’s needs and may lead to inconsistent support. The manager said this person’s plan is in the process of being reviewed and rewritten in a more person centred format. In the meantime he said staff are using ‘information in their heads’ to support the person. As the home is currently using agency staff they must ensure that each person has a written plan detailing their needs and personal goals. The manager agreed to get this 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 12 done. However because the manager is leaving soon a requirement was made to ensure this happens. One person spoke of their hopes and dreams for the future. We found no record or plan to support this so the person may not have the support they need to achieve these goals. The manager agreed to address this as part of the reviewing process. He agreed that staff may need support and training to have the skills they need to develop and implement person centred planning. More work had been done in the second file sampled although it was not complete. Some of the person’s needs are recorded with action by staff to meet those needs. We found that personal goals for the future are recorded including ‘to be more independent and have a holiday’ but there is no plan in place to say how this will be supported by whom and by when. We found no plan to show how staff intend to support skill development leading to greater independence. We found good monitoring in place for example records of how people are feeling etc We discussed with a service user and the manager the possibility of people being more involved in this monitoring. For example staff complete a personal care tick sheet and a toiletries inventory tick sheet when the service user has the skills, with the right support, to do this. The service user and manager agreed that there is potential and interest for some people to be more involved. Plans showed regular review by the manager. The manager said that service users meet with their key workers each month to review their plans. Placement reviews are held with funding authorities and families etc are invited. The manager said that no person centred planning meetings have been held yet. This means that people may not have the full involvement and support from their friends and family to achieve their hopes and ambitions. Support plans have clear and easy to read risk assessments, which have identified the potential risk and give staff strategies to use to reduce the risk. The manager is reviewing these assessments each month. Risk assessments are also completed every time anyone goes out. A service user was observed completing their own risk assessment before they went out. A service user said ‘every time I go out I do a risk assessment’ Historic known behaviours are ticked on a sheet but no mention of current mood, well-being or frame of mind so no mention of how likely the risk is at that time. If likelihood is not considered staff may not put in support strategies making the process a paper exercise. Work has started on writing ‘communication passports’ for each person. One was sampled and had information like what my best day looks like and my worst day. This is clearly written with service users involvement and currently work in progress. The challenge will be for staff to continue this good start. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 13 Some people have communication needs. We observed staff communicating effectively with service users. Some work has been done to make information more accessible including adding pictures and symbols to individual activity planners. The written menu is on display in the kitchen. Service users said they do not always know who will be on duty so they do not know in advance who will be supporting them. They said they guess or ask staff. The manager said that the rota for the day/week is not currently displayed for service users. The home should consult with service users about this so people know who will be supporting them. We found that people have support to make choices about how to spend their day, what to wear, what to eat. With further development of person centred support plans choice and decision-making could be further supported and developed. The AQAA says they could be better at involving service users in the recruitment process. Sections about how they have improved and how they intend to improve are blank. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16 and 17 People who use the service experience good outcomes Service users have opportunity to take part in a range of activities including community-based activities. People have the support they need to make new friends and keep in touch with family and friends. Service users have a good diet and are involved in food planning and preparation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a weekly activity planner that includes evenings and weekends. These have pictures and large print to make them more meaningful. We found that service users have support to access a range of in house and community based leisure activities. The manager said that current staff vacancies have meant some opportunities are limited. When asked about weekends activities one service user said ‘it depends on the staff’ The manager hopes that when two new permanent staff start work at the home soon opportunities will not be limited. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 15 One person goes to college and others attend various classes including keep fit and dance held locally. People access the community regularly like the local shops etc and there is a vehicle for people to use. No one currently is employed and one person said they would like a job. However a plan is needed to support this. We found no plans to support skill development like cooking, money, and medication awareness. The manager said this would be addressed when the person’s plan is reviewed and rewritten. We found that relationships are supported with details of people’s friends and family recorded and records of contact kept. Service users have support to keep in touch with their friends and family. Some people attend local discos and interest groups enabling them to meet new people and make friends. Service users said they are involved in the running of the home and have support to help with the cooking and cleaning. Service users said they do their own laundry with support. Service users are fully involved in food preparation and planning. Service users had support to go and do the weekly food shop during this site visit. Service users said they cook for themselves once a week and help with the food preparation regularly, for example people were making their own lunch. We found that service users have a say about what is on the menu so people get to choose their favourites and alternatives choices if there is something they do not like. The menu is written and is displayed in the kitchen. There is plenty of fresh fruit around the home and service users can access the kitchen for drinks and snacks. The AQAA says they could be better at having more structured weekends activities. How they have improved is blank and they plan to improve by supporting people to have more control of their money and medication. 351 Maidstone Road DS0000061864.V368922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good outcomes. Personal care needs must be recorded to ensure people get the support they want and need. People have the support they need to stay healthy and medication practice is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We found that some people’s personal care needs are not recorded so they may not get the consistent support they need in the way they prefer. The manager agreed to address this as part of the review of support plans. We found good monitoring records relating to personal care. Staff currently complete these records. The manager and a service user agreed that there is potential for service users to be more involved in this recording process. This will give service users more responsibility, skills and control over their personal care. Most of the bedrooms have en suite shower facilities. There is also a communal bathroom and shower. One service user said that they like having their own shower. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 17 Health needs are recorded in service user plans with action staff take to support people to stay healthy. We found that staff work closely with health professionals to support people and make referrals for support when necessary. Staff supported one person to attend a health appointment during this site visit. People’s health is monitored in their plans so staff can pickup any changes in people’s health and well-being. We found that regular health checks are supported; a service user said they go out to an optician in the town. We found that medication is stored securely and medication administration records (MAR) are in order. Systems are in place to make sure that medication practice is safe. Currently staff have control of people’s medication in that staff have the keys and administer to people from the medication cupboard and sign the MAR. The manager agreed that there may be potential for some people to take more control of their medication with the right support. The manager said he would consult with service users and staff and develop support plans to increase service users control and skills. The AQAA says they have improved by carrying our regular competency assessments with staff to make sure staff are still competent at medication administration. The plan to improve section is blank so they may not know what needs improving for service users. 351 Maidstone Road DS0000061864.V368922.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes. Service users know that their complaints will be listened to and acted on. Service users are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a company complaints procedure that has some pictures and photos of whom to complain to. The AQAA says that each person has been given a copy of the complaints procedure. Service users said they would talk to staff or the manager if they had a complaint about something. The Commission have received no complaints about the home since the last inspection. There is a whistle blowing and safeguarding vulnerable adults policy and procedure. This means that staff have the information they need if they suspect someone may be at risk. Staff attend regular training in how to recognise and respond to possible abuse. There has been an adult protection investigation since the last inspection, which is now closed. The home worked with the agencies involved and took action to address the issues raised. The AQAA asks how they have improved and how they intend to improve, these sections are blank. 351 Maidstone Road DS0000061864.V368922.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 and 30 People who use the service experience good outcomes. Service users live in a clean safe home but the garden needs attention to make it more appealing and comfortable for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A service user and the manager showed us different parts of the home and garden. There are spacious communal rooms including a lounge, separate dining room, laundry room and kitchen. Each person has their own room and most have en suite shower facilities. Bedrooms are personalised and service users spoken to said they are happy with their rooms. The home was clean and smelled fresh during this site visit. Access to the rear garden is not restricted so people can go outside for fresh air when they wish. Service users said they are keen to grow vegetables in the garden. The garden is large and not overlooked but is in need of some attention, for example some railings have chipped paint, there is no seating 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 20 and the grass needs cutting and generally tidying. This would enhance the garden for service users and make it a nicer place to be. The front door of the house leads straight into an office. The manager said he works here and holds meetings here. There is a computer here for staff use only. During the visit people were calling at the door including a maintenance man and delivery man and walking through this space. Staff enter this way as do service users so this is not a good place to have an office especially if the manager is working on the computer (the screen can be seen from the door) or making phone calls or having meetings relating to service users. This office also encroaches into service user’s space and does not lead to a homely feel when you enter the home. The manager agreed that the computer, desk and filing cabinet could be re sited to a more appropriate part of the home. There is a separate office for staff use. Service users have keys to their room but no one has a front door key. The front door is kept locked so has to be opened by staff from inside and outside. The manager agreed to consult with service users about having and using a key to the front door with the right support. The AQAA says that the home provides a homely, clean, hygienic environment. How they have improved and how they plan to improve sections are blank. 351 Maidstone Road DS0000061864.V368922.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, 34 and 35 People who use the service experience good outcomes There are enough qualified staff to meet service users needs. Recruitment checks are robust protecting service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently some staff vacancies and permanent staff and agency staff are used to cover shortfalls. The manager said that 2 staff have been recruited and will start in post as soon as the required recruitment checks have been done. We found that staff vacancies are having an impact on the service. The manager said he missed the last 2 managers meetings due to having to cover staff shortages and a service user said that activities ‘depend on staffing’ There were 2 staff (including one agency) on duty with the manager on the day of the site visit. Staff work early and late shifts and 2 staff sleep in at night. There is usually two staff on duty including a team leader. The company have a training manager who organises mandatory courses for staff and training related to specific service user needs. Training is more focused around service users needs and person centred support. This equips 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 22 staff with the skills they need to support service users more effectively. New staff complete an induction that is in line with the Minimum Standard. A staff file was sampled. We found that recruitment checks are carried out before people start work at the home. This protects service users. A service user said they have met two new staff who have been for interviews. The manager said that service users meet prospective staff when they come to the home for their interviews. He said that staff ask service users for their opinions about prospective staff. This means that service users can have a say about who will potentially support them. The AQAA says that staff retention is good and training is provided that relates to service users needs. Parts of the AQAA asking what could be better at the home and how they intend to improve over the next twelve months is blank. 351 Maidstone Road DS0000061864.V368922.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, 39 and 42 People who use the service experience adequate outcomes. The home is run in service users best interests although the management has been inconsistent. Service users know their health and safety will be protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager has been in post for about a year. He has not applied to be the Registered manager and therefore has not passed the fit person process. The manager spoke with knowledge of service users needs and was observed to have a good rapport with service users and staff. The manager said he has handed in his notice and plans to leave the home within the next couple of weeks. He said there has been no handover with a new manager as the recruitment process is not yet complete. There have been three different 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 24 managers in the past three years with a period with no manager when the area manager was overseeing the day-to-day management of the home. This means that there has been a lack of continuity and consistency for service users and staff. The worry is that there could be a period of instability without a manager or while a new manager gets to know the service, staff and service users. The section in the AQAA relating to what could be better and what has improved in this area- conduct and management is blank. We found that the manager reviews support plans every month. There are regular audits by all parts of the organisation including health and safety and training. An area manager carries out monthly monitoring visits and there is more of a focus on outcomes for service users at these visits. The manager said that service users views are sought at monthly meetings they have with their key workers. An example of a change made following the opinions and views of service user was given by the manager in that the shopping day was changed as service users felt it conflicted with other planned activities. The manager said the company are currently reviewing the quality assurance system to ensure it is effective and gives feedback at a local level. Currently the people who use the service are invited to comment informally about how things are going. In addition to this, there is a more organised system that enables them and their relatives to make suggestions about how the service might be improved further. This should be developed further and lead to an annual quality report about the service, about what has improved and how they intend to improve further. The AQAA showed that the required health and safety checks are carried out. The manager has ensured that the required checks and certificates are in place relating to the gas and electrical systems as required at the last inspection. Fire checks and drills are carried out as required. The current registration certificate has outdated information. The manager agreed to send this back to the Commission to get it updated and notify us of the changes in management. We found that some sensitive information about service users was on a shelf by the front door and not stored securely to ensure privacy. The manager removed this information and locked it in the staff office during the visit. 351 Maidstone Road DS0000061864.V368922.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 26 No 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 YA6 Regulation 15 Requirement To ensure that people’s needs and personal goals are supported each person must have a clear up to date service user plan that they have been fully involved in. Timescale for action 31/10/08 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 YA24 Good Practice Recommendations To ensure that the current office by the front door does not encroach on service users living space, staff should consult with service users about a more suitable place for the manager’s office. 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 351 Maidstone Road DS0000061864.V368922.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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