Inspection on 06/08/07 for 88 - 90 Offham Road

This inspection was carried out on 6th 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

88 - 90 Offham Road 17/05/06

88 - 90 Offham Road 07/09/05

88 - 90 Offham Road 17/05/05

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 ADULTS 18-65 88 - 90 Offham Road West Malling Maidstone Kent ME19 6RD Lead Inspector Debbie Sullivan Key Unannounced Inspection 6th August 2007 09:35 88 - 90 Offham Road DS0000029266.V343236.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 88 - 90 Offham Road DS0000029266.V343236.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. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 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 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) MCCH Society Limited Mrs Ann Patricia Francis Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Two service users whose date of birth are: 11/05/1934 and 27/03/1926 Service Users to be 50 years and over The home is restricted to provide residential care for one female service user less than 50 years, whose date of birth is 16/07/1964. Date of last inspection 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 area. The home is registered to offer 24hour care to a maximum of 7 service users who have learning and physical disabilities and who are aged 50 years and over. 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. Ground floor bathrooms are equipped with specialist equipment to assist people with physical disabilities. The premises are not equipped with a lift; consequently not all areas of the home are accessible to wheelchair users or those with limited mobility. Each service user has their own bedroom. There is open plan communal space on the ground floor comprising of a living and dining area leading into the large kitchen. The home has a large mainly lawned, fenced rear garden. The premises are within a few minutes walk of West Malling town centre, which offers a range of local facilities and services. Service users have opportunities to take part in activities at the home and in the community, and activities are geared to ages and abilities. The staff group is well trained and knowledgeable about the service users individual needs. Fees are on an individual basis and assessed according to need, information on the cost of the service can be gained by contacting the organisation. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over six hours. During the visit time was spent with the manager, service users and support staff. The house was toured and a range of records and documentation were read. Staff and service users were friendly and helpful in providing information throughout the visit. Information to assist the inspection was also gained from the annual quality assurance assessment document completed by the manager, and from survey forms returned by service users, relatives and health and social care professionals. Staff had supported service users in completing their forms. The home was full at the time of the inspection. What the service does well: The home provides a comfortable and homely environment that is well maintained, investment is made in improving the property within a reasonable timescale when the need is identified. Bedrooms meet needs and reflect the personalities of the service users. Where there are changing needs due to health or ageing they are well met, and staff seek advise from and have good relationships with outside professionals. Health and personal care needs are well documented and the home strives to meet health care needs with support from others. The staff team is more established and staff like working at the home, they are knowledgeable about individual needs and responsive to learning about new ways to manage any changed needs. Staff are very committed to providing a good standard of service. Staff feel well supported by the manager and together have worked hard to meet the majority of requirements and recommendations from the last report. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Medication procedures need to be further improved upon. Some risk assessments and goals on care plans need updating. The daily recording of meals taken by service users needs to always include full details of each meal. Staff must always sign daily log entries and the manager be notified of any areas of concern. Areas of flaking paint in one downstairs bathroom must be repainted. All staff must undertake Adult Protection training at the earliest opportunity. All records of staff supervision must be held on the premises. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 88 - 90 Offham Road DS0000029266.V343236.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 88 - 90 Offham Road DS0000029266.V343236.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): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and up to date information is available for prospective service users and they are able to visit and spend time at the home before moving in. Needs are carefully assessed and service users only admitted if needs can be fully met. EVIDENCE: The home has a statement of purpose and service users guide that is clear and accessible for service users as it is available pictorially. It is updated for any prospective service users if changes to staff or the premises take place so that it is completely accurate. Photos of staff and the premises are included. The manager has prepared a new pre assessment document that includes pictures and can be used alongside other assessment information from outside professionals. A survey form from a care manager stated, “From what I have seen so far the service assessment appears to be good”. A service user who moved to the home on a temporary basis in January from another MCCH house due to increased mobility needs was familiar with the 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 10 service, has settled well and their needs were being met, it is very likely they will stay permanently. A service user had stated that they “visited before moving in” on their survey form. Should there be any further change in the service user group the home knows that it will need carry out very careful assessments in terms of compatibility due to the increasing needs of the current group, in most cases due to ageing. The care plans seen contained contracts. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain comprehensive information and service users are involved in completing them. They are supported in taking acceptable risks, however some risk assessments require updating Service users are consulted about the running of the home and are able to contribute to it. EVIDENCE: Three care plans were read, two were those of service users over 65. Each service user has a main and health care plan file, person centred planning has been introduced and the care plans showed that service users had been involved in the content. The office has been reorganised and care plans are now stored there rather than in the dining room. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 12 Care plans include review recording, risk assessments, a record of personal preferences such as for personal care, activities, or in the event of death, realistic goals, information on health needs and appointments and reports from other agencies. Service users had signed some of the content personally. Risk assessments were very clear, a number needed updating as did one service user’s goals. The manager was aware of this. The needs of service users over 65 are reviewed by the home monthly; this had been raised as a reminder at a recent team meeting. Background personal and family information was also on the plans. A daily log is maintained for each service user, whilst these gave a good picture of notable daily events, some entries had not been signed and one record of a concern over a service user had not been reported to the manager. During the inspection staff offered each service user choices and opportunities to make decisions such as what to wear, when to eat breakfast or lunch, what to have for lunch, and when to have a bath. Staff took care to spend time supporting each person with their decisions and to guide them sensitively when necessary. As the needs of the service users are very diverse, staff were able to show that they were aware of how much support each person needed, this is helped by better consistency in staffing. Regular service user house meetings are held. Service users are supported in taking acceptable risks, one service user who needs to be supported to go out due to the possibility of them absconding has new guidelines in place for this, another goes out independently most days and prepares their own meals. Service users help with cooking and housework and outside activities are risk assessed. 88 - 90 Offham Road DS0000029266.V343236.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in activities of their choice, although sometimes staffing levels are not sufficient to support all activities on a daily basis. Service users are supported in maintaining relationships with friends and families. EVIDENCE: The ages of the service users at the home cover a wide range; three service uses are currently over 60,the eldest being 81.Staff and the manager said that over recent years the older service users have expressed a preference to stay at home more, in some cases this is due to health reasons. Those who are still more active take part in a range of activities including a theatre group, horseriding, bowling and social activities with other MCCH 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 14 services, an arts and crafts session, and social clubs. Staff take service users shopping, to the cinema, out for meals and on other outings whenever possible, the home has an accessible vehicle and one service user has their own motability car. One service user who was recovering from mobility problems had expressed an interest in attending a local Salvation Army club and was to start attending with a friend at the home. Regular personal shopping and banking is done on a one to one basis. One daily logbook recorded a service user recently going clothes shopping. Current concerns over the health of two service users that were very apparent during the inspection had meant that sometimes staff had needed to delay outside activities with others. They said that activities such as banking or shopping were never put off for more than a day, but the need to devote time to often unpredictable health needs meant that these activities could be curtailed. The staffing levels had also not allowed for service users to have a holiday so far this year. The manager had purchased equipment for more in house activities and was hoping to use a specialist arts and crafts service on an individual or group basis, and to introduce aromatherapy for service users who chose these services. The manager had undertaken work on staffing hours for the consideration of more funding so that more staff were available for times when individual service users needed more time, although the local authority was not increasing any funding at present. The organisation was also looking at possibly realigning hours. During the inspection all the service users were at home most of the time, one went out with staff to a medical appointment, another was going out independently later, others were looking at magazines of their choice, spending time in their rooms or listening to music or watching TV in the living area. The open plan living area being the only communal apace in the home other than the kitchen can curtail opportunities for service users to access activities of choice. When staff suggested the TV go on for some service users at around lunchtime another who had had their music on in the room all morning was not happy with this, it is acknowledged by the service that the living area is not ideal. Service users are supported in maintaining links with friends and families, three service users with birthdays near each other had recently had a joint party in a hall to which families were invited. One had kept the decorations from their cake and was clearly very pleased with them. The same service user regularly invites their girlfriend to dinner and meets her outside of the home. A survey form from a relative states that “I speak often on the phone to my (relative)”. There is no set weekly menu, meals are chosen on a daily basis and recorded. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 15 The recording of some meals needs to be expanded upon; a few lunchtime entries just said “sandwiches”, not stating fillings. Meals are healthy and varied; two service users who like to prepare their own food are monitored so that they have a good diet. Service users can help with food shopping if they wish. A pictorial menu file has been developed. Lunchtime during the visit was relaxed, with staff eating and chatting with service users, the wishes of those who chose to eat in their rooms or later were respected. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 32 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are well met and staff are knowledgeable about individual needs and preferences. Any concerns over health are swiftly referred on to appropriate agencies. Medication procedures have improved but there can be further improvements made in recording. EVIDENCE: Personal and healthcare needs are very well documented in the healthcare files and main care plans. Health needs are diverse and staff manage each persons’ needs well. The majority of the service users have epilepsy; the home is in regular contact with an specialist epilepsy nurse and health care plans had guidelines put in place by the nurse for the management of seizures. On the day of the inspection a service user who has experienced a period of ill health recently was again feeling very unwell, they had refused to go to bed the previous night, remained on the sofa and were incontinent of urine. Staff 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 17 tried to encourage the service user to go to bed or have a bath and called the GP who prescribed some medication. The manager also discussed concerns and appropriate action with care management. The service user did later bath and appeared to feel a little better, and staff continued to gently encourage them to have a rest in their room. Throughout the visit staff respected the needs and privacy of the service user, and sought appropriate advice. Ongoing concern over this service user is to be investigated via a GP referral to mental health services. At the same time the health of another older service user was causing concern and staff were managing this well. Input from health professionals is well documented and regular health checks are kept up. A service user went for a regular check at a diabetic clinic and a District Nurse called to confirm a day to visit during the inspection. A survey form completed by a health professional states that “they (staff) all seem to be very capable of understanding and providing care for this client group” and “Carers very industrious and enthusiastic re. applying their increasing knowledge”, this is in relation to a specific health care need. A form sent in by a care manager stated “Responds well to changes in poor health ---monitor changing needs very well ---always advised of any deterioration.” Staff are provided with training relating to specialist needs such as epilepsy and diabetes and have become more aware of age related issues. Medication is securely stored, and staff administering medication have been trained to do so, medication procedures had improved with any changes in medication made over the telephone by GP’s being recorded on MAR sheets. One MAR sheet inspected had gaps in recording in respect of one service user on one day; the manager was to investigate this. Wishes in the event of death were seen to be recorded on some care plans and as long as needs can continue to be met, the home will support terminally ill service users to be cared for at home. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have access to the home’s complaints procedure and where necessary are supported by others in raising any concerns or complaints. Service users are protected from abuse by the policies and procedures in place. EVIDENCE: The home has a complaints procedure that is accessible to service users. There had been no complaints recorded since the last inspection, a member of staff spoken with said that they had experience of assisting a service user in complaining. Survey forms returned by relatives showed that they were aware of how to complain. Service users are protected by the home’s recruitment procedures and there were no open adult protection alerts. Staff are aware of adult protection procedures, they are induction training includes awareness of procedures and the organisation provides adult protection training and updated training. The training matrix records where a need for initial or updated training is required. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 19 The rights of service users are recognised and protected, one is using an advocacy service, and there are robust procedures for the recording and storage of service users finances. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 20 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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, clean, homely and well-maintained environment. Bedrooms reflect individual needs, tastes and interests. Choice of activity can be restricted due to the provision of only one communal living area. EVIDENCE: The house is clean, well decorated and maintained and provides a homely and comfortable environment. Since the last inspection a number of environmental improvements have taken place, these include redecoration and recarpeting of the living area, the fitting of wash handbasins in bedrooms that had been without them, repairs to a bathroom, purchase of a washing machine with a sluice facility and outside areas have been made tidier and safer. One bathroom downstairs had some areas of flaking paint that need attention. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 21 Bedrooms meet service user’s needs and are personalised with pictures, photos, personal furniture and ornaments, each room is decorated in the occupants’, choice of colour scheme. Should the service user who has transferred from another MCCH home move in permanently they will be able to redecorate as soon as a decision is made. A service user said their room was “alright”. Service users with mobility difficulties are in downstairs rooms, there is no lift. Rooms for wheelchair users are spacious and service users have other personal equipment if they need it, such as a walking frame. A request for a service user who uses a wheelchair to have a new chair has been made. The home has four bathrooms; the downstairs ones are equipped with specialised equipment. As the lounge/dining room is the only communal sitting area, it can limit free choice of activity. The need to review this arrangement is an outstanding requirement. The manager advised that the organisation is now looking at ways that it may make best use of properties for the future. The kitchen is spacious and service users were accessing it freely chatting to staff or preparing their own drinks or meals. The back door from the kitchen leads into the large garden, there is a ramp in place and the lawn has been levelled to make it safer. One service user who smokes was using the patio area and at times another service user was outside for a short while. The manager hopes to improve the garden more next year. There are two laundry rooms at either end of the building; a washing machine with a sluice facility is now installed in one of them. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A staff team that is competent and committed to providing good service and is knowledgeable regarding individual needs supports service users. Current funding restrictions do not allow for there to always be sufficient staff on duty to fully meet the needs of all the service users. EVIDENCE: Staff are clear about their roles, the home is staffed by two senior support staff members and support staff and over the past eighteen months the group has become more established with less use of bank or agency hours. Due to holidays and sickness some bank staff were being used, they are those familiar with the service and one member of bank staff on duty confirmed this. Staff were observed to work well as a team and comments from staff included “It is a good staff team here, people work well together”, “it is a nice house” and “It is demanding at present”. The latter comment was in relation to the increased needs of some service users leading to the need to sometimes devote most time to health and personal care needs, whilst trying to meet the needs of all the service users as fully as possible. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 23 The lack of increased funding from the Social Services department is not allowing for sufficient staffing at all times. Staff said they try to be as flexible as possible and spend individual time with those who have lesser needs when they are at home. Regular staff meetings take place and the manager and senior undertake the regular supervision of staff. The senior has taken a supervision course. Some supervision records were not held on the premises, staff spoken with confirmed supervision takes place. The manager stated they would ensure that in future all supervision records are available for inspection. Recruitment records were not inspected as they are held centrally and not at individual MCCH houses, a CSCI Performance Relationship Manager audits recruitment records for the organisation twice a year. At the last audit no major shortfall in recruitment procedures were found. Some staff training and personal records are held at the home. The training matrix clearly identifies when training needs to be renewed, and service specific courses such as introduction to autism, diabetes and person centred planning are offered. The manager stated that they would address the need for a staff member to have adult protection training; circumstances had so far prevented attendance. A number of staff who have not yet gained an NVQ in care qualification are now enrolled on the course. Currently the home has not yet gained the target of 50 of staff qualified but is working towards it more now the group is more established. Staff observed during the visit were cheerful, caring, had good relationships with service users, used safe working practices, and were knowledgeable about each service user’s needs. Comments made on survey forms sent in by relatives include “They (staff) are very caring and understanding”, “They are there for (service user), that’s what they do best” and “we find everybody very helpful and friendly”. A survey form sent in by a care manager stated “Quite an active household with staff interacting well and enabling residents to get the best out of the day”. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 24 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): 37,38,39,40,41,42 and 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run in the best interests of service users and staff, and service users benefit from living in a home that has a friendly and welcoming atmosphere. EVIDENCE: The atmosphere in the home is friendly and welcoming, the manager is experienced and suitably qualified. The home is well run and organised and staff are aware of policies and procedures and safe working practices. Staff are delegated responsibility for some safety and maintenance checking such as the “walking route”, medication, and COSHH management and updating, and equipment is tested and maintained. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 25 Fridge and freezer temperatures are taken daily, water temperature tested weekly and fire equipment is tested and serviced. The manager had raised a need for a new fire panel recently, fire practices take place. The manager circulates a quality assurance survey annually; the last was in October 2006,forms returned by relatives were positive about the service. Service users have regular house meetings and their views are taken into consideration as a matter of course, this was evident during the visit Comments on CSCI survey forms sent in by relatives and health and social care professionals were all positive about the service. These included from relatives “ we know, (relative) is very well looked after. We couldn’t ask for anywhere better”,” My (relative) who’s been at Offham Road for a long time is very happy and looks well—has come on in leaps and bounds” and a comment from a care manager that “manager always completes incident forms ASAP and works well with care management and staff to obtain good outcomes”. Staff feel well supported by the manager and that she is able to action improvements, one commented “the manager gets things done”. The office is well organised and policies and procedures and other information are readily available for staff. Policies and procedures were sampled and updates had taken place when necessary, adult protection was revised in March 2007.The manager keeps up to date with new policies and is on an MCCH Mental Capacity Act working party. The staff team has aims and objectives set for themselves within the organisations aims. Investment has been made in the property over the last year and any need for further improvement is passed on to the organisation and landlord. The manager keeps clear financial records in respect of the service and service users individual finances and records are stored securely on the premises. 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 26 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 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 3 25 3 26 3 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000029266.V343236.R01.S.doc 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 16 17 3 3 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 88 - 90 Offham Road Score 3 3 2 3 3 3 3 3 3 3 3 Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA10 Regulation 17(1)(a) Schedule 3 Requirement “The registered person shall maintain in respect of each service user a record which includes the information, documents and other records specified in schedule 3 relating to the service user” In that all daily log entries must be signed and any areas of concern be refereed to the manager or senior staff. 2. YA20 17 The registered person shall make arrangements for the recording, safekeeping, recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. In that all staff must complete MAR sheets fully leaving no gaps. The manager undertook to speak with staff regarding this as soon as possible after the inspection. 13/08/07 Timescale for action 13/08/07 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 28 3. YA30 13(3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. In that areas of flaking paintwork in a downstairs bathroom must be repainted. 30/09/07 4. YA24 23(2)(h)(i) The registered person having regard to the number and needs of the service users provide communal space suitable for the provision of social, cultural and religious activities appropriate to the needs of service users and suitable facilities are provided for service users to meet visitors in communal accommodation which is separate from service users private rooms. In that consideration must be given to accommodating the personal preferences of service users regarding the need for an alternative living space/visitors room, and converting current or future vacant bedrooms for this purpose. This requirement is repeated from the previous inspection. The manager stated that the organisation has begun to consider the future use of properties. Any progress on this in respect of the service must be submitted to the Commission and an update provided by the given date. 30/11/07 5. YA35 18(1)(a) “The registered person shall, having regard to the size of the care home, the statement of DS0000029266.V343236.R01.S.doc 30/09/07 88 - 90 Offham Road Version 5.2 Page 29 purpose, and the number and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform” In that all staff must receive adult protection training. 6. YA36 17(2) Schedule 4(f) “The registered person shall maintain in the care home the records specified in Schedule 4” In that all staff supervision records must be available in the home at all times. 10/08/07 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. Refer to Standard YA6 Good Practice Recommendations It is recommended that revision of goals and risk assessments included on care plans take place where they have not recently been reviewed. It is recommended that daily meal choices always be recorded in detail. 2. YA17 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 30 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 88 - 90 Offham Road DS0000029266.V343236.R01.S.doc Version 5.2 Page 31 - 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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