Inspection on 17/05/05 for 88 - 90 Offham Road

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

88 - 90 Offham Road 06/08/07

88 - 90 Offham Road 17/05/06

88 - 90 Offham Road 07/09/05

88 - 90 Offham Road 20/01/05

88 - 90 Offham Road 01/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE 88-90 Offham Road West Malling Kent ME19 6RD Lead Inspector Lynnette Gajjar Unannounced 17 May 2005 10:00 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 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 Older People and 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. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 88-90 Offham Road Address West Malling Maidstone Kent ME19 6RD 01732 874295 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MCCH Society Limited Mr Grahme Kennedy CRH Care Home 7 Category(ies) of LD Learning Disability (7) registration, with number of places 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Two service users whose date of birth are 11/5/1934 and 27/3/1926Service users to be 50 years and over Date of last inspection 20 January 2005 Brief Description of the Service: 88/90 Offham Road is one of a number of registered care homes managed by MCCH Society Ltd in the south east of England. The home offers 24-hour care to 7 service users who have learning and physical disabilities who are aged 50 years and over, with a strong emphasis on older persons care for the current service users. The home is accessible for 3 wheelchair users on the ground floor with a further 4 bedrooms on the first floor. There are 4 bathrooms (2 on the ground floor and 2 on the first floor) .The ground floor bathrooms are equipped with specialist equipment to assist people with physical disabilities. The premises are not equipped with a shaft lift, consequently not all areas of the home are accessible to wheelchair users or those with limited mobility. Service Users accessing the first floor are required to be ambulant in using a stairway. Each sevice user has his/her own bedroom. There is open plan communal space on the ground floor, with no separate communal space available to Service Users to use for privacy or personal leisure activities away from the main routines of the home. The premises are within a few minutes walk of West Malling town centre, which offers a range of local facilities and services 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first in the year running from April 1st 2005 to March 31st 2006. The visit lasted from 09:35am until 16.00pm. The home currently has seven service users and has no vacancies. The visit was spent talking directly with service users both privately and collectively; three support staff, two senior support staff and the registered manager. Due to the nature of the service, it is difficult to reliably incorporate accurate reflections of the service in the report. Some judgements about quality of life and choices were taken from direct conversation with service users and observation followed by discussion with support staff and evidencing records held at the home. A tour of the premises was undertaken. What the service does well: What has improved since the last inspection? What they could do better: 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 6 Service users would receive increased continuity of staff support if the management of staff absences included sickness absence monitoring. Service users lifestyle and living space would be greatly improved if there were separate quiet communal area/s, which could be used away from the more noisy open plan living area. The garden could be used to greater advantage by elderly and frail service users with limited mobility, including wheelchair users, if safer access, pathways and seating were installed. Casual staff would have a better awareness of any changes to service users care needs if a strong audit system was put in place to ensure care plans were regularly reviewed and updated. Staffing between the hours of 10 pm and 7 am should be reviewed. This would allow for safe moving and handling practice for those service users requiring two staff to give personal care and offer greater flexibility in times of rising and retiring. 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. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,5,6 Service users are given all the information they need to be able to make an informed decision to live at 88/90 Offham Road. EVIDENCE: Service users have access to a statement of purpose and service users guide, which give good representation of the service provided in the home in a format that is easy to follow. The home has not had any new admissions for over a year but service users remembered and talked fondly of visits to the home a number of times for meals, social events and sleep overs to get to know everyone. Records seen fully supported this and the assessment process. Care plans contained a written tenancy agreement, which gives the service user’s security and rights of residency and details the tenants and landlord’s rights and responsibilities. The service users have made use of the organisation’s housing officer, who reminds service users of their tenancy 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 9 agreement, helping them to understand it through visits, letters and discussion. This home does not provide intermediate care. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The health, social and personal care needs of service users are well supported with regular contact with specialists and external professionals. Service users are treated with genuine respect and dignity by support staff. EVIDENCE: Through discussion with a service users and sharing of their care plan, it is clear that service users are given full support and encouragement to maintain personal contact with practices nurses, GP, community learning disability staff, epilepsy specialist nurse and consultants, as well as chiropodist and dentists, to maintain good standards of health and well being. A service user shared “sometimes the doctor comes here or I go to him, it depends”. Records seen 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 11 were sufficiently detailed and contained clear information to support staff to meet the needs of the individual, with some minor retyping needed to make the guidance easier to read. Monthly reviews are not taking place for those over 65years. Staff and the manager have openly tried to resolve issues regarding bed routines for service users who require two staff to carry out safe moving and handling practice. The agreement reached could still be viewed as restricting personal choice when service users wish to go to bed, as only one member of staff is on duty after 10pm. The manager evidenced ongoing discussion with senior managers, care manager and staff regarding the additional staffing implications. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Service users are given encouragement and support to make choices about aspects of their daily lives, including access to a range of local social and recreational interests. The open plan communal area adversely affects service users individual choice and personal space. EVIDENCE: Continued support from staff enables individuals to access West Malling amenities and the local area including shopping, bowling, walks in the park, meals out, and attending leisure sessions within club connect. A service user shared “staff take me out, but don’t force you if you don’t want to”. Staff 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 13 showed a good understanding of individual interests, physical ability and a respect for a slower pace of life. A service user recently celebrated their 70th birthday and received cards and gifts from local businesses in the village, with whom they have regular contact. The age and mobility of current service users can restrict contact with relatives and friends. Staff help with writing letters and providing transport for planned visits. Two service users continue to go out unaccompanied locally within their agreed care plan and maintain their independence within the village. Ground floor building alterations were carried out 18 months ago. The result being an open plan communal area, which is busy, noisy and always-in use. Service users do not have access to any quiet areas other than their own bedrooms. A service user who smokes cigarettes respects the homes no smoking policy by smoking outside. When discussing how service users felt about care in the home and if there is anything they would like to change, a service user left the room and returned with a catalogue opened at the page with conservatories, “somewhere to sit quietly and have a cigarette”. Two other service users joined in at this point and said this would be nice, as “it gets noisy at times”. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Service users feel confident to raise concerns or complain, as they know they will be listened too and action taken to resolve them. Protection from abuse is promoted through staff training and understanding of the support and actions they may need to take. EVIDENCE: Service users spoken with knew who to talk to if they had a concern or wished to make a compliant, this included support staff, the manager, nurses and the inspector. Copies of complaints are recorded with outcomes and monitored by the organisation senior management. Copies of the written and pictorial complaint procedure are available in the home. Staff who have been spoken with over a number of visits continue to evidence a good understanding of how to protect and prevent abuse, including reporting under local procedures. Staff show a good understanding of limitations that might impede personal choice, as detailed earlier in this report 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,25,26 Service users live in a warm, nicely decorated and clean home. Personal choice and lifestyle is restricted by the open plan communal living area. Safe access to the garden is severely restricted for elderly service users with limited mobility. EVIDENCE: Following major building alterations 18 months ago, communal living is now shared between 7 service users rather than the smaller homes of 3 & 4. Service users have to share the open plan kitchen/dining area and lounge. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 16 The only private areas are staff and individual service users rooms. Those with limited mobility are unable to access friends’ bedrooms on the first floor. During this and previous visits, service users, staff and relatives continue to comment and express how restrictive this is and that it’s not nice to have nowhere to go to get away from the hustle and bustle of daily routines or have private conversation. The majority of service users spoken with do not wish to use their rooms to talk with friends and visitors, or just to get away from the TV. Doorways and hallways continue to be badly damaged due to the width and size of electric wheelchairs. Redecoration, furnishings and carpets are in hand for service users private rooms from this year’s budget. Room visited were personally decorated to individual tastes and had personal effects. The garden is not fully accessible by those service users who are elderly and frail, or with physical disabilities. There is no safe flat surface to walk on. Pathways with railings, suitable adaptations and well placed seating would greatly improve access and use of the garden. Service users when asked about the garden shared “it’s a shame, I’d like to sit out there when the weathers good but can’t” “ I would like to go out there more but can’t get my wheelchair out there without help from staff”. Staff mentioned good relationships with neighbours at bottom of garden but because service users cannot get there, they end up shouting at each other from the small uneven patio or communicating via staff. The home has adequate bathing and toilet facilities with adaptations and equipment to meet their needs. Risk assessments need to be completed in relation to infection control, cleaning and use of commodes in service users bedrooms. No bedrooms have washbasins and interim measures have been implemented where staff carry antibacterial vaporisers to clean their hands. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 The high levels of staff sickness limit the stability and consistency of care provided to service users, and effective team working. EVIDENCE: Rosters seen during the inspection showed staff self-certification sickness to be very frequent, this has affected the stability of the staff team and restricts consistent support to service users. The manager has reduced the use of agency staff since the last inspection through the use of regular casual staff employed by MCCH. Staff continue to attend in house one-day training courses relevant to this service user group. Two staff hold NVQ 2 in care and two staff continue to work towards NVQ 3 in care. Due to pressures on the roster, other NVQ training has currently been suspended. One senior support worker is nearing completion of NVQ 4 and the other holds the NVQ Assessors award. Staff on duty today evidenced a good understanding of service users support needs through the positive relationships formed between them and service users. Currently the home staffing agreement is for one sleep over staff on duty from 10pm to 7am. This restricts service users choice of times to get up and go to bed when requiring two carers for safe moving and handling. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 18 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,36,38, The manager is supported well by two senior staff who together promote leadership in the home, enabling staff to understand their roles and responsibilities in supporting the aspirations of service users. EVIDENCE: 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 20 The home has good management structure offering clear lines of accountability and understanding of roles and responsibilities. Service users and staff expressed a high regard for the management approach to the home. Service users felt the registered manager was approachable and staff said they felt well supported. The manager and senior staff demonstrated through discussion a very clear understanding of the needs of current service users and issues relating to their care. Monitoring health and safety in the home is to a good standard with weekly walking routes carried out. Equipment is serviced as required to maintain a safe home and facilities. Risk assessments are completed for individuals, staff activities in the home and care duties. Staff evidenced a clear understanding of accident/incident reporting. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 x 5 3 6 N/A HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 2 3 3 3 x 2 3 Score Standard No 7 8 9 10 11 Score 3 3 3 3 x Standard No 27 28 29 30 2 2 x 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 x COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 2 x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 3 34 x 35 x 36 3 37 x 38 3 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 22 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 YA 24 OP 19 Timescale for action Written 23 The registered person shall (2)(h)(i)(o having regard to the number and response )(4) (a)(c needs of the Service Users:· The detailing the action communal space provided for taken to Service Users is suitable for the address provision of social, cultural and religious activities appropriate to this, is to the circumstances of the Service be sent to Users.· Suitable facilities are the commissio provided for Service Users to n by 14th meet visitors in communal July 2005 accommodation, and in private accommodation which is separate from the Service Users private rooms· External grounds, which are suitable for, and safe for use by Service Users, are provided and appropriately maintained. The staff stated that work requests had been submitted to the housing dept and MCCH Society Ltd and they are aware of this. No further action has occurred. 23(2)(j)1 he registered person shall having Written 3(4)(c) regard to the number and needs response of the Service Users ensure detailing that:· There are provided at the action taken to appropriate places in the premises sufficient numbers of address H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 23 Regulation Requirement 2. YA30 OP26 88-90 Offham Road washbasins fitted with hot and cold water supply.The registered person shall ensure that—(c) Unnecessary risks to the health or safety of Service Users are identified and so far as possible eliminated. Following the last two inspections it was identified from a site visit by the Housing dept that major work was required to the shower and bath water inlets to the home. Due to funding issues and work priorities, it had been agreed to suspend installation of the sinks until 2005 .Staff were unaware of this being planned within the 2005 budget year but could not confirm this. this, is to be sent to the commissio n by 14th July 2005.. 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 OP7 YA6 Good Practice Recommendations Simple auditing and monitoring sheets and colour coding should be introduced to the care plans to assist staff with the review process. Staff should review the current daily recording method and detail recorded, to evidence the good support and observations seen during the inspection. It is recommended that risk assessments relating to those over 65 years be reviewed at least monthly or more often as care needs change. It is strongly recommended that a full review of nighttime support and care for a specific service user is undertaken to ensure that the home can safely meet their care needs within current staff roster without compromising service user choice. It is recommended that that staff stop writing personal information in the communication book but refer the reader to individual file care records in accordance with the Data Protection Act 1998. It is recommended that risk assessments and clear H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 24 2. 3. OP7 YA9 OP 14 YA 8 4. OP14 YA10 5. OP26 YA30 88-90 Offham Road 6. OP27 YA33 OP29 YA34 7. infection control assessment is undertaken with detailed procedure for handling, disposing and cleaning of waste from commodes. Provision for proper sluicing facilities should be explored. It is strongly recommended that a review of the staff complement be undertaken to ensure adequate staff are on duty to meet the moving and handling care needs of service users after 10pm. It is recommended that human resource staff files are reviewed with auditing and monitoring systems implemented to ensure required information are obtained, recorded, and filed in a manner that is easy to track and monitor 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone KentME16 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. 88-90 Offham Road H56-H06 S29266 88-90 Offham Road V220023 170505 Stage 4.doc Version 1.40 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. 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!