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Inspection on 07/08/07 for 492 Maidstone Road

Also see our care home review for 492 Maidstone Road for more information

This inspection was carried out on 7th August 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 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is a friendly and welcoming atmosphere in the home and challenging behaviour is well managed. There is strong leadership for staff and the staff team are enthusiastic. They provide a supportive environment in which the service users can maximise their independence. The home is good at offering appropriate choice to the service users. The residents participate in a range of activities and are able to lead meaningful lives. The health of the service users is carefully monitored and all aspects of health are promoted. There are sound procedures for management and administration of medicines within the home. Nutrition in the home is good, healthy eating is encouraged and special eating needs are supported. The home makes good use of local community facilities. They are well supported to use the health care services and local amenities.

What has improved since the last inspection?

The way the home is managed has significantly improved. In the three months he has been in post, the registered manager has made very good progress in a number of areas. These include the way medicines are managed, the way challenging behaviour is managed and the introduction of the concept of Person Centred Active Support (PCAS). The care plans have improved significantly. They have all been reviewed and redesigned in line with PCAS. The home has improved the way in which it supports the service users to maximise their independence. There is now a wider choice of activities offered to the service users. There is a more stable staff team who now have a greater understanding of the needs of the service users. The bathroom has been redesigned to provide a smaller bathroom and a shower room and toilet. Some bedrooms have been redecorated and new sofas have been provided for the lounge. The garden has been tidied and a new fence has made it safer for the service users and given the neighbours more privacy.

What the care home could do better:

Whilst there have been some improvements to the environment more work is still required. There are a number of areas in the home that need attention, for example: - the trickle vents on some windows are damaged and will be energy inefficient during the winter; some furniture is tired and unattractive; the utility area, that includes the laundry facilities, is cluttered and lacks a hand washing facility. In particular, the kitchen requires urgent attention to ensure it is safe, hygienic and homely.

CARE HOME ADULTS 18-65 492 Maidstone Road Blue Bell Hill Chatham Kent ME5 9QN Lead Inspector Wendy Mills Key Unannounced Inspection 7th August 2007 10:00 492 Maidstone Road DS0000064371.V345491.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 492 Maidstone Road DS0000064371.V345491.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. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 492 Maidstone Road Address Blue Bell Hill Chatham Kent ME5 9QN 01634 869716 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) glebe.house@theavenuestrust.co.uk The Avenues Trust Limited Mr Daniel Steven Gower Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 4. Date of last inspection 16th January 2007 Brief Description of the Service: 492 Maidstone Road is a residential home providing care and support up to four people with profound learning disabilities. The home is in Bluebell Hill Village, a residential area situated between the towns of Maidstone and Chatham. The centres of both towns are approximately five miles away. The home is within a few minutes reach of the M2 and M20 road links and is close to a bus route. The nearest shops, GP surgery and other local amenities are located at Walderslade village. This is approximately one mile away. The home is one of a group of community homes owned by the local Primary Care Trust (PCT). It is managed and run by the Avenues Trust. Services provided include personal support and in house and community based leisure activities. Health services are arranged and accessed through local health care teams. The accommodation is provided in a bungalow. There are four single bedrooms, a lounge, kitchen/diner, bathroom, shower room and utility area. Outside there is a safe and enclosed rear garden. There is room to park up to five cars to the front of the premises. The weekly fees for this home are £1,852 per service user. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key visit formed part of the inspection process by the Commission for Social Care Inspection (CSCI) in accordance with the Care Standards Act 2000. This report takes information gathered since the last inspection. The sources of this information include feedback from staff at the home, visiting health and social care professionals, relatives and the home itself. On the day of this visit there were four service users living in the home. During this visit, it was possible to speak, in depth, with the manager and support workers. The views of visiting health care professionals were sought. Time was spent with the service users, interacting with them and directly and indirectly observing the way in which they interacted with staff. Due to the communication difficulties of the service users it was not possible to reliably elicit their views but it was possible to make an assessment of their comfort, choices they make and the quality of their daily life within the home. Documentation, including, care plans, staff files and health and safety records were examined and a tour of each part of the home was made. Direct and indirect observations were made throughout the visit. The home has made good progress in meeting the requirements and recommendations placed at the last inspection. A new manager, Dan Gower, has been appointed. He is very experienced in social care and holds good formal qualifications, including the National Vocational Qualification at Level IV (NVQ 4) in Management and Care. He has successfully completed the process for registration with the Commission for Social care Inspection (CSCI) within the last two months and is now the Registered Manager for the home. All comments received about the home were very positive. The service users, staff and manager are all thanked for the welcome they gave and for their assistance throughout this visit. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The way the home is managed has significantly improved. In the three months he has been in post, the registered manager has made very good progress in a number of areas. These include the way medicines are managed, the way challenging behaviour is managed and the introduction of the concept of Person Centred Active Support (PCAS). The care plans have improved significantly. They have all been reviewed and redesigned in line with PCAS. The home has improved the way in which it supports the service users to maximise their independence. There is now a wider choice of activities offered to the service users. There is a more stable staff team who now have a greater understanding of the needs of the service users. The bathroom has been redesigned to provide a smaller bathroom and a shower room and toilet. Some bedrooms have been redecorated and new sofas have been provided for the lounge. The garden has been tidied and a new fence has made it safer for the service users and given the neighbours more privacy. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 7 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. 492 Maidstone Road DS0000064371.V345491.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 492 Maidstone Road DS0000064371.V345491.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&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the service users and supporters, with the information they need in a way they can understand. Appropriate assessments are made. This ensures that any changing needs of the service users are identified and met. EVIDENCE: The home has a Statement of Purpose and a Service User Guide that are written in Plain English. These documents provide good information for the supporters of the service users. These documents are unsuitable for the service users and other ways are found to ensure that they can understand their rights whilst living in the home. Direct and indirect observation confirmed that they are very much at home and can make their wishes clearly known by non-verbal communication. No new service users have been admitted to the home since the last inspection but recent, full and thorough, reassessments have been carried out for all of them. This documentation was examined and found to be in very good order. 492 Maidstone Road DS0000064371.V345491.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 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The needs of the service users are properly assessed and they are offered appropriate choices in a way they can understand. This promotes their selfesteem and independence. EVIDENCE: Since the registered manager came into post, he has arranged for the thorough reassessment of all the service users. He has introduced the concept of Person Centred Active Support (PCAS). This ensures that all care planning is focused on the potential of an individual to improve. It also ensures that individual needs are met. The staff said that the manager has led strongly in the introduction of PCAS and that they are now beginning to see the benefits as the service users are making progress. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 11 The care plans have all been reviewed and redesigned. They are well set out and contain pictorial information that helps the service users understand and contribute to their care planning as much as possible. Appropriate risk assessments are in place for all aspects of their lives. Direct and indirect observation showed that choice is offered appropriately. Choice is offered on an “either or” basis rather than offering too great a choice at one time. Too much choice can be confusing for the service users. The service users all have long established behaviours. This means that they tend to make the same choice all the time. This can lead the continuous choice of negative and repetitive behaviours. Recently, more choice, in the way of activities, has been offered, supported and encouraged. Now all the service users are beginning to choose more positive activities. For example, they are choosing to be more active during the day, to help to prepare their own food and to get themselves dressed. Conversation with the registered manager showed that there is good planning to progress the independence and integration of the service users in the future. For example, at present, some of the service users enjoy swimming but have always attended a special facility but now that they are making good progress with their behaviours, their goal will be to use the local swimming pool instead. 492 Maidstone Road DS0000064371.V345491.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, 15, & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users participate in appropriate activities both within the home and the wider community. This means that they can lead interesting and meaningful lives. EVIDENCE: Since the last inspection there has been an increase in the number and variety of activities available. On the day of this visit two of the service users went out for lunch. The service users who remained in the home were supported to make their lunches. Later one enjoyed eating his lunch in the garden and the other joined us over coffee in the kitchen. The service users participate in activities such as music sessions and have one-to-one attention from staff who work with them to improve their skills in activities of daily living such as dressing and personal care. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 13 Activities outside the home include swimming, walks and outings. Due to the complex needs of the service users a high staffing levels (two staff to one service user) is required when time is spent out in the community. The home provides transport and staff to support the service users when they make visits to their families. In cases where relations live a long distance away, regular telephone contact is made. The home is now working to help one service user contribute to a letter home each moth. This is being done on the computer and uses pictures in order to allow as much participation by the service user as possible. In most cases, relatives act as advocates for the service users but the home has access to advocacy services should this be indicated. Since the introduction of PCAS the service users have made good progress. They all have long established behaviours. This makes it difficult for them to change quickly. However, they are all now working towards realistic goals and making good progress. In the past, the service users did not contribute to the day-to-day chores within the home. Now they are beginning to enjoy kitchen duties, especially preparing meals. Some are spending less time in their rooms or in destructive behaviour. Documentation is now well maintained and incidences of challenging behaviour are being more carefully monitored. Care plans are well-maintained and clearly identify activities that are planned and activities in which the service users have participated. Nutrition in the home is well managed. The manager holds the budget for food and ensures that there is a good choice of healthy and nutritious food available. Choice is offered appropriately and advice from health care professionals is sought and followed for those service users with eating difficulties. On the day of this visit the service users who were at home were observed to choose what they wanted to eat, to help prepare it and to eat well. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 14 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. The home actively promotes the health and well-being of the service users and respects their privacy and dignity. EVIDENCE: The health and personal care needs of the service users are recorded in the care plans. Direct and indirect observation showed that staff respect the privacy and dignity of the service users. They were observed to knock on bedroom doors, give gentle prompts when personal care was indicated and to speak in a kind and gentle manner. Examination of documentation showed that appropriate healthcare appointments are made and kept. The home seeks the advice of specialist healthcare professionals such as the speech and language therapist and the dietician. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 15 The registered manager has reviewed the procedures for the management and administration of medicines in the home. He has arranged for the medicines used in the home to be provided by a local pharmacy. This service is due to start on the week beginning 13th August 2007. This change will mean that the home has a more local and personal service. Medicines are well managed in the home. Storage is safe and secure. There is a storage facility for controlled drugs but no controlled drugs are used in the home at present. Only staff trained in the administration of medicines are allowed to administer medicines. The Medication Administration (MAR) sheets are in order. The service users are very good at taking their medicines and there are sound procedures for this. None of the service users is able selfadminister their medication. It was very encouraging to note that the registered manager has a particular interest in ensuring that there is strict attention to detail in respect of the management and administration of medicines in care homes. Conversation with him confirmed that he is both knowledgeable and conscientious about medication. He is commended for his diligence in this aspect of care. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 16 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. The home responds appropriately to concerns and complaints and has sound systems in place for the protection of vulnerable adults. EVIDENCE: There are sound policies and procedures for the handling of complaints and concerns. The manager and the company are quick to respond to any concerns raised with them. Staff have been trained in the Protection of Vulnerable Adults (POVA) and are clear about their responsibility to report any concerns they may have in the respect of the way the service users are treated. The manager has an open door policy and staff know that they can approach him with concerns at any time. There are regular one-to-one staff supervision sessions and staff meetings. The manager is experienced in dealing with challenging behaviour and has been helping staff give calmer responses to some of the more difficult behaviours that the service users may exhibit. This minimises the risk of harm from some of their behaviours could cause. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there have been some significant improvements to the environment, work is still required to ensure that the service users have a hygienic, homely and safe place in which to live. EVIDENCE: Since the last inspection work has been carried out to convert the large bathroom into a smaller one and to add a shower room and toilet. This has been very successful and means that it is much easier for staff to support the personal hygiene needs of the service users. Both the bathroom and shower room are very clean. Staff are commended for their diligence in ensuring the toilet is clean at all times. It is cleaned three times each day, at least. However, ventilation in the bathroom could be improved. The only window that opens is quite small and has an inadequate catch. There is an extractor fan but again, this is quite small. When this is due for replacement, the company should consider fitting a more robust extractor fan. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 18 Some bedrooms have been redecorated since the last inspection. In as far as possible, they are personalised, however, some behaviours exhibited by the service users require that there are some restrictions in order to protect them from harm. For example, it would not be safe for some of the service users to have ornaments in their rooms. These restrictions have been risk assessed and agreed with families and care managers. Some bedroom furniture has been heavily repaired and is now looking tired and out of date. New and more robust furniture would make the bedrooms look more homely. One room would benefit from a sturdy, custom made, fitted unit It is very good that the service users are positively encouraged to use the kitchen, with support, at all times. However, this does mean that the kitchen units have had a lot of use by the service users and have suffered from their over-enthusiasm. Some cupboard doors have been so badly damaged that they have had to be removed and there is no longer a set of kitchen chairs. Those chairs that remain are badly stained. Staff said that they feel embarrassed when visitors are asked to sit on them. There is no separate hand-washing sink in the kitchen. This compromises food safety and hygiene. The kitchen requires urgent attention. A full assessment of the area should be made. Ideally the kitchen should be redesigned. The current, domestic quality fixtures and fittings should be replaced with more robust quality, custom-made furniture that is able to withstand the heavy treatment it will inevitably receive. The utility room serves as both the laundry, and for storage of substances and equipment that may be harmful if the service users were to have access to them. This room is small and cramped. It has no hand-washing sink. This room would also benefit from a full assessment in respect of infection control measures and efficiency, although this work is not so urgent as that needed in the kitchen. There are a number of other areas in the home that require attention, for example, the trickle vents on some of the widows are broken. This means that the home will be energy inefficient when winter comes. Since the last inspection the home has greatly improved the garden area. It is now a pleasant and safe place to sit. It has plenty of shade and some sunny spots as well. It was good to see that the service users had been shopping for new plants for the garden and that there were plans to plant these out over the next few days. It was also good to note that the plants they had chosen had great sensory effect in scent, visual appearance and feel. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 19 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 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels, staff morale and staff training have all significantly improved. Recruitment practices are sound. This means that the service users are supported by a carefully vetted, motivated and skilled staff team. EVIDENCE: There is a good gender, age and ethnic mix in the staff team. Inspection of a sample of staff files and training records shows a good level of training. There is one-to-one supervision for staff. This is where training needs and individual performance are reviewed. There are regular staff meetings and staff said that the manger fosters an open and honest working environment where the opinions of staff are taken seriously. They said that staff views are listened to and acted upon appropriately. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 20 The company has strict and robust recruitment policies and procedures. The Criminal Records Bureau (CRB) and references are stored at the company’s head office but copies of tracking forms are held in the home. These forms include the CRB numbers. They were inspected and found to be in order. The company has always made it clear that original records will be made available if requested. These records were not requested at this visit. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way the home is managed has improved significantly. The home is run in the best interests of the service users. Their needs are identified and met and their health and well-being is promoted. The views of their supporters and staff are listened to and acted upon. EVIDENCE: The registered manager, Dan Gower, has only been in post for three months. In that time he has met the requirements for registration with the Commission for Social Care Inspection (CSCI) and established a clear and strong leadership role in the home. He is well qualified for the role of registered manager. He holds the NVQ level IV in management and care, the Registered managers’ Award (RMA) and the D32/33 (NVQ assessor’s qualification). 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 22 The registered manager has maintained his continuing professional development and is planning to embark on a management diploma course this coming September. He has a many years experience of working in care settings and has particular expertise in the management of challenging behaviour. In the short time that the registered manager has been in post he has supported staff to better manage challenging behaviour, established more robust supervision and identified areas for improvement in the home. Conversation with him showed that his is very knowledgeable about best practice in care and has a commitment to continuous improvement. Staff spoke very highly of his input to the home and about the way he listens to concerns and acts upon them. They said he is always ready to listen to them and is prepared to work alongside them when necessary. During this visit the registered manager was able to readily produce all documentation that was requested. However, he has to work in a small room that also serves as the staff sleepover room, the place for storage of medicines and a passageway to the staff toilet. This area would benefit from an assessment to see if there is any way in which it could be made more efficient. For example, if another area could be found for some document storage and the storage of medication, this room would be much more useable. The service manager make regular visits to the home on behalf of the company. Regular reports are submitted to the CSCI in accordance with Regulation 26 of the Care Standards Act. 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 23 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 2 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 X 2 X 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23 Requirement All areas of the home to be safe and hygienic. In particular, the kitchen should be assessed and action taken to make it safe and hygienic. Timescale for action 30/11/07 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 Refer to Standard YA25 YA1 Good Practice Recommendations Bedroom furniture that has been repaired should now be replaced. A review of the usage of the manage r’s office/sleepover room/medicines storage room should be undertaken 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 492 Maidstone Road DS0000064371.V345491.R01.S.doc Version 5.2 Page 26 - 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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