Inspection on 17/10/06 for 57 Pembury Road

This inspection was carried out on 17th October 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

57 Pembury Road 14/12/05

57 Pembury Road 02/09/05

57 Pembury Road 19/10/04

57 Pembury Road 26/07/04

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 57 Pembury Road Tonbridge Kent TN9 2JB Lead Inspector Lynnette Gajjar Unannounced Inspection 17 October 2006 09:50 th 57 Pembury Road DS0000023887.V303233.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 57 Pembury Road DS0000023887.V303233.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. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 57 Pembury Road Address Tonbridge Kent TN9 2JB 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) 01732 354949 The Avenues Trust Limited Doreen Phyllis Forward Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Age range 40 - 65 Care of one service user is restricted to one older person whose date of birth is 05/02/1940 Date of last inspection Brief Description of the Service: The Avenues Trust Ltd who has owns 57 Pembury Road also have a number of other care homes in the southeast. The home provides accommodation and care for 4 men who have learning disabilities, one of whom also has mental health difficulties. The accommodation is arranged on 2 floors with one ground floor bedroom. There is a small bathroom and separate toilet on the first floor and a shower room on the ground floor. There is a lounge and kitchen diner with access to the laundry and shower room via the kitchen. The home has steep stairs to the first floor and is therefore unsuitable for those less ambulant or who are wheelchair users. There is a small garden and patio to the rear and parking for up to five cars to the front. It is a detached house within walking distance of Tonbridge town centre and sited on a busy main road. The home’s current fees scale ranges from £985.48 to £1008.05 per week. Additional charges include chiropody £16 per session, toiletries, magazines and barber these charges vary depending on service users’ choices. The Avenues Trust contributes £150 per year towards service users’ holidays and £6 per week to activities. The last inspection report can be located in the staff office in a file named ‘CSCI’. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the key unannounced inspection, for the year running from April 1st 2006 to March 31st 2007. The visit lasted from 09:50am until 17:00pm. 57 Pembury Road has 3 gentlemen in residence who have lived together for a number of years the home is running with one vacancy. The visit was spent talking with three service users at different periods of time due to their activities. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of the service users in the report. Some judgements about quality of life and choices were taken from direct conversation, observation and physical responses with those living in the home followed by discussion with staff and the manager, evidencing records and care plans held at the home. A tour of the home was undertaken. All three-service users completed CSCI “feed back questionnaires”, as well as four relative and two G.P’s. All indicating they were overall satisfied with the care provided. The report also uses information provided by the manager through a detailed questionnaire. Comments shared through the feedback questionnaires included: “Like going to pubs” at weekends “ I am good at spelling” “ I would like to make more decisions” “I hope there is someone nice who is going to take (name) room” “I like a lie in” “Looked round the house, I chose the room” “I choose my bedroom before we moved in” “Staff always appear to have good knowledge of patients, give excellent care have warm friendly interaction.” “I have found that (name) is looked after very well in Pembury Rd and is learning a lot more now than he did when he was in a larger unit. One to one care is best if possible.” “All staff at 57 Pembury Rd are friendly, efficient and the residents are content and happy and kept healthy. My relative would not want to be anywhere else, he is well cared for.” What the service does well: 57 Pembury Road provides a welcoming home in a residential area of the town with shops and other amenities such as church, pub and post office within walking distance. The home and individual bedrooms are personalised and reflect the interests and lifestyles of those living here. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 6 The gentlemen living here feel supported and encouraged by staff to be involved in all aspects of their daily lives to the best of their ability. Being encouraged to take part in the local community, follow personal interests through a varied social and leisurely lifestyle including annual holidays at a pace suitable to them. Those living here through the positive interaction with staff and the manager feel genuinely liked and respected. The gentlemen presented as being relaxed and comfortable with staff indicating they feel safe and secure at the home. They are encouraged and supported in making decisions and choices to maintain an independent lifestyle as possible. The staff team continue to actively promote good relationships with family and relatives. What has improved since the last inspection? What they could do better: The home is generally furnished to a satisfactory standard; through the refurbishment of the kitchen units, work surfaces and tiles staff and residents can promote good infection control and basic food hygiene requirements. This is an on going requirement from the previous inspection. As recommended in the last inspection because of the location of the ground floor shower room it is recommended that a partition be erected to separate the access via the kitchen in order to preserve the Service User’s privacy and dignity. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 7 Service users and staff would feel safer and more secure through the reassessment and serious consideration of installation of gates to both sides of the property restricting access to the back garden and entrance. Large items of furniture awaiting refuse collection in the front garden should be removed as quickly as possible. Those living here would benefit from staff having clear guidelines and information regarding when to administer PRN medication, safe and separate storage of internal and external medication and staff having regular assessments in their understanding and safe medication practice. Staff can develop further the daily records by making sure accurate details of the support and care given, opportunities for choices, how the person has felt, been involved etc, to reflect the guidelines and assessed plan of care. For the ease of tracking and completing care plans, a review of current duplication of risk assessments and guidelines and their storage would reduce the risk of confusion to the most recent and accurate documents to follow. Service users would feel more secure in the knowledge that financial systems and monitoring are fully reviewed following the findings of the adult protection investigation and recommendations. With independent auditing of personal monies are undertaken on a regular basis. 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. 57 Pembury Road DS0000023887.V303233.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 57 Pembury Road DS0000023887.V303233.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): 2,3,4,5 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The gentlemen living here and their representatives have access to the information needed in making a decision as to whether the home can best meet their needs. EVIDENCE: The home is currently running with one vacancy. A prospective service user had been assessed for this but the home did not feel they could meet their needs satisfactorily. The manager detailed a thorough assessment process, which would have included visiting them in their current residence, discussion with service users, relatives and other professionals, leading to visits, trial over night stays before deciding to move into the home. The manager has a good understanding of the compatibility needs of those living her and where the home is best suited to meet individual care needs. There are currently no new assessments taking place. Ongoing assessments and support is provided through other professionals such as Learning Disability Teams nurses, various health consultants and their GP. Two of those living here reflected back on looking at the home and being involved in deciding whether to move in.” Looked round the house, I chose the room” ‘I chose my bedroom before we moved in”. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 10 Care plans contained a written tenancy agreement, which gives the persons’ security and rights of residency, detailing the tenants and landlord’s rights and responsibilities. 57 Pembury Road DS0000023887.V303233.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): 6,7,8,9,10 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Person centred care plans, risk assessments and guidelines continue to develop offering detailed information to ensure consistent support by staff to meet the individual health and social care needs. Better tracking and recording of support and care given would reduce the risk of missed information, duplication and evidence of good care provided. EVIDENCE: Through discussion with the manager and assessing two current care plans, direct observation and conversation with service users, it is clear that those living here are given full support and encouragement to maintain personal contact with health and social care professionals, to maintain good standards of health and social care. Personal likes and dislikes are clearly recorded. However the three-file set up should be reviewed as they lead to duplication, potential risk of missed reviews/appointments and access to the latest information. Through the introduction of a review-tracking sheet at the front of each section this will aid monitoring, reviewing documentation and appointments. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 12 Guidelines and risk assessments continue to develop to help staff to access information that is most important and to maintain individual and collective goals safely. Pictorial and object referencing is being introduced here and to the ‘my file’ care plan that is better understood by those living here. Daily write-ups seen are in a tick box format with sections for more expansion, in the form of a more detailed summary of the care and support given and reciprocated. Further development of how these are used would give a clearer picture of personal choices; dignity and support needed. Yearly care management reviews have been undertaken. Key worker meetings have not been recorded as happening as regularly as expected. The manager acts as appointee for two service users monies. Power of attorney is arranged for the third. Service users access their personal monies for personal spending with staff support. A full policy and risk assessment review is currently being under taken following an adult protection investigation relating to service users financial management. Independent formal audits are not undertaken for personal monies. Interaction between the residents and staff continues to be good showing genuine respect, friendship and appropriate familiarity with each other. Records seen were stored securely. 57 Pembury Road DS0000023887.V303233.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): 11,12,13,14,15,16,17, Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The gentlemen living here are given encouragement and support to make choices about a range of local social and recreational interests at a pace suitable to them. The menus and food provided offers the quality, nutritional value and healthy fresh products. EVIDENCE: The gentlemen living here are able and encouraged to follow hobbies and interests of their choosing and the staff know individual personal preferences. Discussion with service users and looking at photographs reflect that a steady, though flexible routine occurs on a day - to -day basis and individuals feeling safe with this. Routine is important for those living here. Other opportunities include: leisure outings such as the local pub as a particular favourite, having ‘meals out’ particularly birthdays, and walks to the park. Other occasional opportunities include trips to theatre, shows; daytrips to the coast and travelling on trains were discussed and photographed shared. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 14 Others prefer watching personal videos, TV, listening to music and puzzles, art and drawing. One service user who has retired attends two different local church luncheon and social clubs. Evening activities are preferred to relax at home watching their favourite soap operas and programmes mainly in the privacy of their rooms with going to local Gateway clubs and events fortnightly. Service users currently attend religious services they choose. All service users have at least two/three planned activity days at places of education or work experience such as Pepenbury, Riverside and local social services day centre. Personal preferences of getting up and going to bed are observed and respected. Holidays have been taken by all this year, discussion showed how they chose their holidays taking into account their personal interests. Contact with families and relatives are promoted on an individual basis, through visits to their home and short stays, telephone calls and letters. The menu offers a varied and wholesome variety of meals, with ample fresh fruit and vegetables. These are tailored to the specific that those living here like and dislike. The gentlemen are supported to be involved in write shopping lists, and be involved in the preparation and cooking of foods to the best of their ability but requiring full staff supervision and completion of the task. Personal preferences and choices of interaction are respected. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, social and personal care needs of those living here are well supported with regular contact with specialists and external professionals. Those living here are treated with genuine respect and dignity by care staff. EVIDENCE: Staff are clearly aware as to the type and nature of the support required for individual’s personal and intimate care needs. Every effort is made to maintain privacy and dignity when people are being supported with bathing, washing and dressing. Direct observation during the site visit showed personal preferences and wishes being followed. Generally good practice in relation to medication administration was observed. MAR Sheets are clearly signed with the odd gap being already investigated by the manager. Clear PRN guidelines of administration should to be introduced. External and internal medication should be stored separately to avoid contamination. The manager has just completed medication training and is reviewing current house practise and will be introducing regular competency assessments that are overdue. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 16 The staff team have been working closely with Learning disability team and Clinical Psychologist for assessment of people at the home. Strategies have been implemented and counselling requested following the closure of art therapy resources. G.P/practice nurse is within close proximity and regular appointments are made. Not all service users access chiropody care and alternative contacts where discussed. Regular contact with other health resources is maintained on an individual basis. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. Systems are in place to enable those living and those visiting the home to raise concerns or complaints with staff and people they trust. Protection from abuse has been promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: The home has a clear complaint procedure both in written and audio formats. Those spoken with knew who they would talk to in they were unhappy about anything. Comment cards received from service users indicated they knew who to talk to in the event of having a concern but that they only sometimes felt respected and listened too. The home’s records indicate they have not had any formal complaints. Minor disagreements between service users are supported by staff to be resolved and are recorded in personal daily records. Staff who have been spoken with evidenced a good understanding of how to protect and prevent abuse, including reporting under local procedures. A number of staff has just completed training in this area. There is currently one Adult Protection alert open to investigation with one staff suspended pending the outcome. Due to behaviours that may challenge the service, some guidelines have been introduced for those with mental health needs, that do infringe on personal choices and rights but have been assessed and guidelines agreed by multidisciplinary team in the service users best interest. These however do not detail who was part of that team and the signing of the guidelines. This could leave the manager and staff team open to lone accountability. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 18 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): 24,25,26,25,27,28,29,30 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The gentlemen live in a generally clean, comfortable and homely environment, which would be enhanced further by the completion of refurbishing the kitchen and bathing facilities, delivery of new furniture and re-assessment of the garden area to make safer access and better security. EVIDENCE: The home was clean and tidy on the day of the inspection and reflects an all male environment. The kitchen units continue to show signs of wear and tear and need replacing as identified in previous inspection, the manager stated that a new kitchen was planned by the housing association in April 2006 but this has not transpired. As an interim measure quotes have been obtained to strip and repaint kitchen doors. All of the bedrooms are single, spacious and reflect the interests and lifestyles of individuals. Service users are very please with the installation of hand wash basins. One bedroom has had their carpet replaced. The location of the ground floor shower room is not ideally situated to provide privacy for service users and it is recommended that consideration be given to erecting a partition 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 19 wall between the kitchen and this area for privacy and hygiene purposes. Also plaster here is water damaged and poses an infection control issue for a shared facility. New furniture has been ordered to replace that currently in the lounge. Security and access to the side of the property is of concern and serious consideration should be given to fixing gates to the sides of the property to restrict unauthorised access the to back garden, especially as on such an open and busy main road. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 20 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): 32,34,35,36 Quality on this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The gentlemen living here are benefiting from the stabilising of the staff team with new staff being transferred from within the organisation. They receive core training and on-going support in meeting individual needs of those living at 57 Pembury Road. EVIDENCE: Those living here are beginning to benefit from the stabilising of a core staff team following staff transfers within the organisation. Following low staffing levels over the past few months. Staff spoken with detailed a robust recruitment process carried out by the Human Resources department. Before a position is offered a CRB check and verification of two references is obtained. However records held in the home did not support this and a review of information should be undertaken and records copied and transferred from human resources to the home. Faxed details from the head office verified CRB and references for those missing. All employees undergo induction training and job descriptions clarify their roles and responsibilities within the service. One member of staff has an NVQ qualification and one has applied to start this. Training records show that other training courses relevant to the service have taken place. Staff 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 21 confirmed receiving supervision and records seen show that this would exceed six times a year. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 22 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): 37,38,39,42 Quality on this outcome area is good. This judgement has been made using available evidence including a visit to the service. The gentlemen living here have their personal preferences, support and care needs encouraged through the registered managers open leadership, and the promotion of a welcoming home. EVIDENCE: The manager has obtained NVQ level 4 in care and Registered Managers award. She is also a trained NVQ assessor. She has continued to update her training through short courses. The gentlemen through the interaction observed appeared very comfortable and well supported by the manager. A service manager undertakes regulation 26 visits monthly supports the manager in developing action plans and works to be completed. Monitoring health and safety and quality assurance at the home is to good standard, equipment serviced as required to maintain a safe 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 23 home and facilities. The pre inspection questionnaire lists maintenance and associated records. Risk assessments are completed for individual’s activities. As detailed under environment there are maintenance and repair issues remaining to be addressed as well as security access to the sides of the property. The registered manager evidenced a good understanding of accident/incident recording and reporting under regulation 37 to the Commission, with head office monitoring /auditing patterns and triggers. Staff training records showed ongoing training in health and safety, food hygiene, moving and handling, care of the back, fire awareness. The manager monitors this and staff informed when refresher training is required. A full insurance certificate was on display and current. 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 3 4 3 5 3 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 3 26 3 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 3 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 25 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(2) (b) Requirement The registered person shall having regard to the number and needs of the service users ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. In that: The kitchen units are worn and in need of replacement. This is an outstanding requirement from the last inspection. The manager stated interim cosmetic striping and painting of doors was to take place but the housing association was not replacing the kitchen as expected and detailed in the home last action plan. Work must to be completed by the timescale date. 2 YA26 13(2) The registered person shall make 31/12/06 suitable arrangements to prevent infection and the spread of DS0000023887.V303233.R01.S.doc Version 5.2 Page 26 Timescale for action 31/12/06 57 Pembury Road infection at the care home. In that: Exposed plasters and wall coverings in the communal shower room are repaired and easier to clean and maintain basic good hygiene standards. Work must to be completed by the timescale date. 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 It is recommended that a review of the current care planning formats of three files be undertaken to reduce the duplication of information and risk of updates and reviews taking place. This review should include the daily recording and write up sections to evidence better triangulation of care and the style of language used. It is recommended that a review and tracking sheet be introduced to each section of the care plan formats to aid monitoring and reviewing of information and appointments. It is recommended that key worker meetings be undertaken on a regular basis and record action being taken and by whom. It is strongly recommended that financial systems and monitoring be fully reviewed following the findings of the adult protection investigation and recommendations. With independent auditing of personal monies are undertaken on a regular basis. It is recommended that translation of current risk assessments into the easy to follow pictorial and object referencing format continues to enable more service user understanding. DS0000023887.V303233.R01.S.doc Version 5.2 Page 27 2 YA7 3 YA9 57 Pembury Road 4 YA20 It is recommended that clear PRN guidelines of triggers and guidelines are recorded and kept with MAR sheets. It is recommended that staff is assessed at least yearly by a competent person in relation to competent medication administration and Avenues medication procedures. It is recommended that internal and external medication is stored separately. It is strongly recommended where protocols have been assessed and implemented that may infringe on service users rights and choices in a form of restraint. The written protocols should detail other professionals involved in the assessment and where possible their signature of agreement that this is in the individuals best interest to evidence a multi disciplinary approach to care. It is recommended that a partition wall be placed between the kitchen and laundry/shower room. This is a recommendation from the last inspection. It is recommended that laundry that has to be carried through the kitchen be contained in sealed bags or laundry containers. It is recommended that advice be sought from Kent and Medway Infection Control Unit to infection control management throughout the home. It is recommended that the manager continue to work to recruit to all vacant care staff positions. It is recommended that a system be introduced to ensure personnel records required to be held at the home are transferred from Human resource team at time of recruitment or their previous home if an internal transfer. It is recommended that at least 50 of the care staff team be trained to NVQ level or above. It is recommended that large items of furniture awaiting refuse collection in the front garden should be removed as quickly as possible. It is recommended that serious consideration be given to the security and easy access to the sides and rear of the premises. 5 YA23 6 7 YA30 YA30 8 9 YA32 YA34 10 11 YA35 YA42 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 57 Pembury Road DS0000023887.V303233.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!