Inspection on 21/08/07 for 89 Thanington Road

This inspection was carried out on 21st August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

89 Thanington Road 29/08/08

89 Thanington Road 20/11/06

89 Thanington Road 23/02/06

89 Thanington Road 07/01/05

89 Thanington Road 09/06/04

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

CARE HOME ADULTS 18-65 89 Thanington Road Canterbury Kent CT1 3XD Lead Inspector Jenny McGookin Key Unannounced Inspection 21st August 2007 10:00 89 Thanington Road DS0000023728.V346050.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 89 Thanington Road DS0000023728.V346050.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. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 89 Thanington Road Address Canterbury Kent CT1 3XD 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) 01227 764881 thaningtonrd@mcch.org.uk MCCH Society Ltd Post Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th November 2006 Brief Description of the Service: This home is a large domestic style dwelling that has been adapted to meet the requirements of a residential care home catering for people with a learning disability. The registration details show that Mr Peter Thompson is representing Methodist Community Care Housing (hereafter referred to as MCCH) Society Limited as the Responsible Individual, and Mrs Janine Lesley is shown as the Registered Manager, although Tracey Beale was acting manager at the time of this site visit. The home was originally registered to accommodate 5 service users, but the conversion of one double bedroom into a single occupancy room effectively reduced its capacity to 4 users, and the home has in practice been operating with three service users for some time. This should be reflected in the formal registration details. One bedroom is sited on the ground floor within easy access of a WC/ shower room. The other bedrooms are on the first floor. Although there are ramps to the front and rear of the property and there are some grab rails, access to the rest of the premises has not otherwise been adapted to facilitate access for individuals with mobility impairment. The home has a garden at the back where service users can pursue leisure and social activities or horticultural hobbies. The home is about a mile from Canterbury city centre and all the community and transport links that implies, and the home is also on a bus route to Ashford as well as Canterbury, although the nearest bus stop is about 500 yards walk away There is an on-site parking bay for up to seven vehicles as well as unrestricted kerb-side parking on Thanington Road. The service users have had access to a Motability vehicle, the local Park and Ride service, and staff vehicles are also used to access the community. The current fees for the service at the time of the visit are £? per week. Information on the home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service user Guide. The e-mail address for this home is: thaningtonrd@mcch.org.uk 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to review findings on the last inspection (November 2006) in respect of the dayto day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took just over eight hours, and involved meeting with the manager and a support worker. Some limited conversation was possible with two service users but this was not possible with the third on this occasion. Interactions between staff and service users were observed over lunch. The inspection involved a review of the premises and a range of records. Two service user’s files were selected for case tracking updates (all three service users have been subject to full case tracking exercises on previous visits). What the service does well: What has improved since the last inspection? The acting manager has been confirmed in post and will be submitting her application for formal registration by the Commission in due course. Information indicates that she has had a positive impact on the staff and service users. There is evidence of some refurbishment (a new kitchen has been installed and some carpets and linen has been replaced), with more in prospect. The loss of access to Club Connect and the Visiting Persons Team has been addressed positively, and the home has benefited by the acquisition of some of the VPT’s resources and a staff member. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 7 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 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 8 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Although there continue to be no new admissions, policies are in place to ensure this would be managed appropriately. Service users benefit by statements of the terms and conditions of their placements, governing the rights and responsibilities of both parties. EVIDENCE: All three service users were admitted to the home in 1991 and no further admissions are being actively planned. MCCH has been able to demonstrate the home’s capacity to meet the assessed needs of the current service users. In common with the arrangements in other homes in the group, MCCH has a contract with the commissioning agencies, which is kept at its headquarters (i.e. not readily accessible to the inspection). There is also an “Assured Shared Tenancy Agreement for Supported Housing” which has already been assessed as largely compliant with the standard insofar as it describes the landlord / tenant arrangements and the terms and conditions, fees and facilities governing each tenancy. This document is written in generally plain language, so as not to alienate the general public. And this document has an appendix, which was designed to obtain further 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 9 compliance with this standard (e.g. re committing the MCCH to provide personal care, ISP / review process). This appendix is reviewed annually to ensure its currency. It is likely that any prospective service users would have special communication needs, which would need to be catered for. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6,7,8,9,10 Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: The arrangement is as described at the last inspection. Specifically, each service user has to have, as a condition of their admission, a Care Co-ordinator or a Local Authority Care Manager, and the care plans they set up in the first instance. The home has its own care plans, called Individual Service Plans (hereafter referred to as ISPs). The format of the ISPs builds on the initial care plans to provide scope for all aspects of the health, personal and social care needs of the service user to be addressed, and this includes pictures or key words to help ensure communication is effective. Some policies are also in picture 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 11 format. Each service user has two allocated key workers to ensure the ISPs are implemented and developed thereon. The home carries out its own informal reviews of care plans every month, though often without change. The more formal review processes for these service users continue to be led by a Community Nurse (Learning Disabilities), with input from the service user’s key worker, and records show they are being reviewed every six months. In each case, these records show that the service user is invited to participate and whether they stay for the whole meeting. And they also show that other interested parties such as family members are routinely invited. There was good evidence of service users being supported to make their own daily living decisions. And risk assessments are in place to safeguard activities inside and outside the home. The home has generally sound arrangements for keeping confidential information secure against unauthorized access. Only one matter was raised for attention in respect of key holding arrangements. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 11,12,13,14,15,16,17 Services users are supported to make choices about their life styles, and to develop their life skills. Service users benefit from the range of social, educational, cultural and recreational activities. EVIDENCE: This home is judged reasonably well placed in terms of access to Canterbury City Centre and all the community resources and transport links that implies. “Opportunities” records and feedback from staff confirm that daily routines promote individual choice and freedom of movement, subject in each case to risk assessments, so that the service users stay safe. The current service users are reported to be able to understand the spoken 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 13 word but have limited communication skills. The home’s own staff provide some direct support, but also rely on outside agencies for support with other activities. In each case, staff use a range of skills to support them with making choices over their activities. Despite the loss of Club Connect facilities and the Visiting Persons Team, service users are still able to benefit from a range of activities to compare with the examples given at the last inspection - from ordinary everyday events such as light housework tasks (cooking, laundry, tidying and gardening) and on site activities such as puzzles, art, TV, videos and DVDs. There continue to be local outings (bowling, rambling, swimming, shopping, cinema, clubs, banking, meals out and sensory sessions in a day centre) i.e. socially inclusive activities not necessarily restricted to their disability. Service users generally enjoy an annual holiday, though the manager said that one service user’s holiday plans had to be scaled down to day trips and short overnight stays this year because of his poor health. There are open visiting arrangements, and records continue to confirm the active involvement of relatives in the ISP processes. There is a communal phone in the hallway and service users would also have access to the office phone, though they would in each case require staff support because of their limited verbal skills. Visits to and from relatives are supported. Each individual’s nutritional needs and preferences are properly established as part of the ISP processes and carefully monitored and amended on a day-today basis thereon. The manager explained how pictures are used to help service users choose meals, and they also help to buy and prepare meals subject to risk assessment. Staff eat with the service users and eat the same food, which is judged a good quality assurance tool. During this site visit, the service users and staff were joined for lunch and the meal was judged well prepared and presented. The pace of the meal was unhurried and the atmosphere was relaxed and congenial. Service users can also snack between meals. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18, 19, 20, 21 The health and personal care that service users receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The ISP processes properly assess the extent to which each service user requires assistance with their own personal care (and this specifically includes gender preference), and their choice and control is actively promoted by staff as far as possible. In most cases this simply amounts to prompts. All the bedrooms are single occupancy and there are enough toilet and personal care facilities to guarantee their availability and privacy. Staff are available on a 24-hour basis to assist service users, should they require help. The ISP process routinely addresses a range of standard healthcare needs and records have been set up on file to document access to healthcare 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 15 professionals as appropriate e.g. GP, community nursing, optician, dentist etc. so that trends and events can be properly tracked. The manager said that the GPs carry out an annual health check and medication review, and each service user has a Health Action Plan to ensure they enjoy optimum health. Records confirm that none of the service users is currently judged able to self medicate. The medication administration records seen showed no anomalies or gaps and the inspector was advised that the home keeps medication reference material on site. Staff are given training in medication and their competence is subject to annual assessments, to ensure they comply with expected standards. The medication arrangements were, therefore, judged compliant with the National Minimum Standards and found to be in the service users’ best interests. The manager reports that staff have attended loss and bereavement training and have read MCCH policies and procedures governing the ageing process and death. Given the age range of these service users and their relatives, this is judged sound, pre-emptive practice. 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22, 23 Service users are supported to express their concerns They are protected from abuse, and have their rights protected. EVIDENCE: MCCH has policies on complaints and adult protection, which have been judged satisfactory by previous inspections. The manager reports that relatives of the service users have all been issued with copies. The MCCH also a pictureassisted version of the complaints procedure to make it more accessible to service users, and records include a checklist for staff to sign and date as confirmation of their having explained the complaints procedure to the service users. There continue to be no complaints registered since the last inspection, but the manager reports that any concerns are taken up in supervision sessions. The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. There is currently still no active input from independent advocacy services, though MCCH has information on local resources so that arrangements could 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 17 be put in place. The manager said that service users routinely receive polling cards but do not show much understanding of the process. In a meeting with one member of staff he confirmed feedback obtained from other staff at previous inspections, that he was committed to challenge and report any instances of abuse, should they occur. Adult Protection training is routinely made available to staff as part of a rolling programme of mandatory training, and there are policies and guidelines governing the management of behaviours and finances. See also section on “Individual Need and Choices” in respect of risk assessments and ”Conduct and Management of the Home” in respect of health and safety. 89 Thanington Road DS0000023728.V346050.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 26, 27, 28, 29, 30 The physical design and layout of the home enable service users to live safely. The environment is well maintained and comfortable, and encourages independence. EVIDENCE: This key inspection site visit involved a tour of the building and confirmed the investments made since the last inspection. the home’s location (in terms of access to Canterbury) and layout are generally suitable for its registered purpose, and measures are in place to keep the premises secure against unauthorised access or egress. All areas of the home were inspected and found to be homely, comfortable and generally clean. Comfortable temperatures and lighting levels were being maintained. The 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 19 furniture tends to be domestic in style and there were homely touches throughout, including the service users’ own pieces of art and craftwork and photographs. The grounds are reasonably flat (i.e. no outstanding trip or slip hazards) throughout, so that service users can use them with safety, and the garden is landscaped to provide pleasant outlooks from the bedrooms. The home has a “No Smoking” policy. The communal areas of this home are spacious. All the bedroom windows offer pleasant outlooks. The seating in the dining and lounge areas is uniform in style, but this is appropriate, given all the service users are relatively mobile (one uses a wheelchair outside). A new kitchen has been installed and is light, airy, clean and well maintained. There is one communal bathroom, and a shower room/WC and WC i.e. reasonably accessible to bedrooms and communal areas. All the bedrooms are single occupancy, so that service users are assured of privacy. All the bedrooms were inspected and judged well maintained and personalised. Although they were, not fully compliant with all the provisions of the National Minimum Standards in terms of their furniture and fittings, nonprovision was properly justified in ISPs. All the maintenance records seen were generally up to date and systematically arranged. A few matters were raised for consideration or attention at the last inspection, to improve the facilities and level of hygiene, and found to be still outstanding. 89 Thanington Road DS0000023728.V346050.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. 32,33, 34,35,36 Staff in the home are skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. And MCCH reports having succeeded in obtaining 100 NVQ accredited staff to benefit service users. EVIDENCE: The staffing arrangements at this home were judged sufficient to meet the assessed needs of the service users. The manager continues to be available to provide direct care 80 of her time (which is being used to good effect as a quality assurance tool as well as an opportunity to build up a rapport with service users and staff) but is allocated one day a week to carry out purely management tasks There are no ancillary staff, though MCCH has its own maintenance department and a new maintenance co-ordinator - support workers are 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 21 responsible for cleaning the home and also have some grounds maintenance tasks. They are to be commended again on the level of cleanliness found. An examination of personnel records confirmed a robust recruitment process to comply with all the key elements of the standard. The manager reports that all staff routinely receive copies of the General Social Council Code of Practice to underpin the MCCH policies and procedures. The member of staff on duty during this visit confirmed feedback from other staff at previous inspections, that they all have regular supervision sessions, and that the frequency of these sessions is in excess of the National Minimum Standard. These sessions covered all those elements prescribed by the standard. And there are monthly staff group meetings. Staff training records were inspected on this occasion, which confirmed information obtained from staff at previous inspections i.e. that there is a also a very satisfactory level of investment in mandatory training (e.g. moving and handling, medication, food hygiene, First Aid and Health and Safety, COSHH and infection control) to keep the service users safe, as well as some specialist training such as epilepsy, loss and bereavement, and ISP. Since the last inspection, the manager reports that 100 of staff have obtained accreditation to NVQ Level 2 or above. All these elements combine to ensure practice does not become variable, and is compliant with best practice standards. This is judged commendable. 89 Thanington Road DS0000023728.V346050.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 37, 38, 39, 42, 43 The management and administration of the home is based on openness and respect, but there needs to be more effective quality assurance systems. EVIDENCE: Since the last inspection the acting manager’s post has been confirmed by MCCH and will be subject to the Commission’s own formal registration process in due course. Tracey Beal reports that she is currently working towards NVQ Level 4 accreditation and information indicates she has had a positive impact on staff and service users. The structure of the overall organisation continues to offer clear lines of accountability, and generally good use has traditionally been made of the 89 Thanington Road DS0000023728.V346050.R01.S.doc Version 5.2 Page 23 regulatory framework to keep service users safe and to promote their wellbeing. This is a mixed gender team, which continues to report working harmoniously and flexibly to meet the needs of the service users. The service users all require prompting with their personal care, and the deployment of staff is organised to meet their needs and preferences (e.g. same gender care). The processes for managing this home are open and transparent, and the delegation of responsibilities appears to be appropriate. MCCH has a corporate business plan. And Tracey Beal has made a good start with setting up a development plan for the home, which properly makes conspicuous reference to other performance indicators such as budgetary controls and stakeholder feedback. This is judged very promising. There was good evidence of service users being supported to make choices on a day-to-day basis, and there had been a recent mailshot to obtain feedback from relevant stakeholders. There had only been one response to date, so it may well be too soon to evaluate its overall effectiveness as a quality assurance tool. But the response in question (from a visiting social care professional) was invariably positive. Between May 2006 and May 2007 (and with one exception), there had been better evidence of the MCCH carrying out monthly inspection visits of its own, but practice after then appears to have become variable, for want of available records on site. The MCCH is reminded that breach of this regulatory duty is an offence and must be addressed as a priority. This matter has been raised before and is effectively preventing this home from obtaining an overall quality rating of “good”. Records confirmed regular health and safety audits. The home appeared to be generally very well maintained and hazard free. All maintenance records were up to date and systematically stored, so that service users remain safe. 89 Thanington Road DS0000023728.V346050.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 X 3 X 4 X 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 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 2 X 2 3 X 89 Thanington Road DS0000023728.V346050.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 YA39 Regulation 26 Requirement To ensure that the home is run in the best interests of the residents. The registered providers, or an employee not directly concerned with the conduct of the home, must visit the home once a month and write a report on the conduct of the home. The report must be kept available for inspection on site or if requested. Timescale for action 30/09/07 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 YA22 Good Practice Recommendations The challenge continues to be to find ways of translating any expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened DS0000023728.V346050.R01.S.doc Version 5.2 Page 26 89 Thanington Road to and acted on. 2. YA24 Building - the following recommendations are made to improve the facilities and hygiene: • 1st floor WC -very restricted space. Recommend removal of wall separating the WC from bathroom / WC. • Bathroom and Shower room - would benefit by refurbishment; radiators showing signs of rust require attention or replacement; paintwork was peeling off in bathroom; Shower attachment - needs a non-return valve to stop feedback. Bathroom furniture needs updating and doesn’t match; shower cubicle needs through clean. • The use of fabric communal towels should be discontinued as a precaution against the spread of infection • Recommend a sluice or disinfecting cycle on washing machine. There should be a unit-specific business plan, linked to quality assurance initiatives and corporate business planning and auditing arrangements, to obtain full compliance with this standard. The views of service users and other stakeholders will be crucial to the success of this. 3. 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