Inspection on 12/12/06 for 94 Whitstable Road

This inspection was carried out on 12th December 2006.

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

The inspector found 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Whitstable Road 17/01/06

94 Whitstable Road 21/03/05

94 Whitstable Road 16/12/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 94 Whitstable Road 94 Whitstable Road Canterbury Kent CT2 8ED Lead Inspector Jenny McGookin Key Unannounced Inspection 12th December 2006 10:00 94 Whitstable Road DS0000032234.V324241.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 94 Whitstable Road DS0000032234.V324241.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. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 94 Whitstable Road Address 94 Whitstable Road Canterbury Kent CT2 8ED 01227 471980 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) whitstable@mcch.org.uk MCCH Society Limited Post Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seven people with Learning Disabilities at any one time (excluding persons registered or persons employed at the home or their relatives) The residents shall be 18 years of age and over 21st June 2006 Date of last inspection Brief Description of the Service: 94 Whitstable Road is registered to provide accommodation and personal care for up to seven adults who experience a learning disability (residents). In practice, the Home accommodates a maximum of six people because the one double room is used as a single. The Home is operated by Maidstone Community Care Housing, which is a private company, with charitable aims. The Acting Manager is based in the Home and she is responsible for the supervision of its day-to-day operation. This is an older property, which has been adapted for its present purpose. The accommodation is provided on the ground and the first floors. All of the residents have their own bedroom. There is dedicated parking for one vehicle, and the home has a large walled garden to the rear. The home is situated within easy walking distance of local shops, pubs and a train station; it is also on a main public bus route. The City of Canterbury, with extensive shops and amenities is approximately 15 minutes walk away. The home has access to one dedicated vehicle to support residents to get out and about. The current fees for the service at the time of the visit are £262 – 315.13 per week. Information on the home’s services and the CSCI reports for prospective residents should be detailed in the Statement of Purpose and Resident Guide. The e-mail address for this home is: whitstable@mcch.org.uk 94 Whitstable Road DS0000032234.V324241.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 site visit, which was intended to inform this year’s key inspection process. There was an earlier random site visit to temporary premises (in June – while the registered premises were refurbished); and this visit was used to check progress on matters raised for attention on that occasion; and to review findings in respect of the day-to day running of the home. The inspection process took six and a half hours, and involved meeting with the senior support worker in charge. Meetings with other staff had occurred at the temporary site in June. The inspection also involved a complete tour of the premises and the examination of a range of records. Two residents’ files were selected for care tracking, to supplement a case tracking exercise at the temporary site in June. Conversations with the residents were vey limited because of their level of disability, but interactions between staff and the residents were observed during the day. What the service does well: What has improved since the last inspection? What they could do better: The work being done to update public information (Statement of Purpose, Service User Guide and Contract) needs to be completed without further delay, and needs to be readily available for inspection and in formats to meet the special communication needs of residents. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 6 MCCH needs to obtain compliance with the requisite level of NVQ accreditation in its staff team to meet the National Minimum Standard. MCCH needs to better evidence its compliance with its regulatory duty to carry out its own unannounced inspection visits to this home at least once a month. 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. 94 Whitstable Road DS0000032234.V324241.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 94 Whitstable Road DS0000032234.V324241.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 adequate This judgement has been made using available evidence including a visit to this service. 1,5 Although there have been no new admissions, policies are in place to ensure this is managed appropriately. Each placement is subject to terms and conditions governing the rights and responsibilities of both parties, but this document requires further attention. EVIDENCE: 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 9 There have been no admissions since May 2004. One other admission was in 2000, but all the rest date from 1986 or, in one case, from 1988 i.e. long before the emergence of the National Minimum Standards. There are no further admissions being actively planned, but one resident has expressed the wish to move on. Notwithstanding good anecdotal information from staff, Methodist Community Care Housing (hereafter referred to as MCCH) has been required to better evidence the home’s capacity to meet the emerging needs of residents since their admission. There was on this occasion good evidence of consultation and team working to explore the options available to the resident wishing to move on, to enable her to do so. When this service was last visited in June this year, there was only a master copy of the home’s Statement of Purpose, Service User Guide and contract available on site for inspection. An assessment was carried out of the Resident Guide and contract at that visit, and each was judged in need of further attention to obtain full compliance. Time constraints prevented an assessment of the home’s Statement of Purpose. MCCH was asked to ensure each document was fully compliant with the National Minimum Standards and to submit copies of the latest versions of all three documents for the Commission’s reference. This matter was still outstanding by the deadline set and by the time of this visit, though staff said they understood some work had been done on each and that this included a CD to make the information more accessible for people with learning disabilities. Until the work is complete, this effectively means prospective residents and their representatives do not have all the information they would need to make an informed choice. It is likely that any prospective residents would have special communication needs, which would need to be catered for. 94 Whitstable Road DS0000032234.V324241.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: Two residents’ files were selected for case tracking, to supplement the case tracking exercise carried out on the Random Visit in June. But for one recent development (see below) findings from the exercise in June were largely confirmed on this occasion. Each file contains critical information obtained from initial assessments, and evidence of assessments, covering a range of healthcare, personal and social support needs. And there was good evidence of monitoring via charts, observation sheets, activities programmes and risk assessments. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 11 Each resident has an allocated key worker who is tasked to ensure the care plans are implemented and developed. However, until recently it was not clear whether this process obtained any real changes to the outcomes for these residents. There was evidence of monthly reviews being documented and of risk assessments being reviewed on a quarterly basis, but often without change in each case. And the extent to which the residents’ views or aspirations steered the process or were followed up was not clear. However, there was a team “Away Day” at the end of November which was used to significantly redefine care planning objectives for each resident. Examples include leisure pursuits and daily living skills development, improving staff communication skills, better networking with other agencies and further empowering group meetings. And records also show how one resident’s expressed wish to move on has been translated into action plans to explore other housing options. This is judged a very promising development. There was good evidence of the residents being involved and supported in the day-to-day routines of the home, as far as was currently practicable, within staffing constraints, but staffing levels continue to be raised as an issue requiring further investment. These residents are all dependent on the support of staff, and two are non-verbal. Two staff on most shifts would not appear to offer much scope for flexibility. The home’s arrangements for keeping confidential information secure against unauthorized access is judged satisfactory, and confidentiality properly features in MCCH policies and staff terms and conditions of employment. 94 Whitstable Road DS0000032234.V324241.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 People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individuals’ expectations. 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. There was good evidence of activities on and off site, and evidence of the home’s reliance on outside agencies (e.g. day services and clubs, Visiting Persons Team) for other activities. The findings from this visit largely confirmed those of the Random Visit in June. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 13 Each resident has an “Opportunities Planner” which is actually filled in retrospectively after each shift so as to be an accurate record of options actually chosen on the day. This is judged an appropriate arrangement. Daily routines appear to promote independence, individual choice and freedom of movement, subject in each case to risk assessments, so that the residents stay safe. Records indicate that activities inside the home include support in some light practical living skills. For example, one residents’ interest in going around collecting rubbish has been channelled into recycling duties, and another is supported to buy and prepare ingredients for meals. Raised beds are planned for the garden to facilitate one resident’s interest in gardening. All these residents have been judged unable to go out without support, and the front door is secured against unauthorised access and egress by a keypad arrangement. As long as there is a properly documented risk assessment in respect of each resident to justify this – and this was so in the case files selected for care tracking this is judged appropriate (though this will need periodic review to ensure it does not become unduly restrictive). Off site activities include day services (for things like art and craft sessions, sewing, woodwork, music and dance, and group outings) and socially inclusive activities, not readily associated with the residents’ disability such as horse riding, swimming, bowling, meals out, banking, shopping, theatre and cinema. There are open visiting arrangements, and staff described visits to and from families. One resident was supported to go on holiday with family members in Portugal and another in Devon. There is a communal phone in the hallway and residents would also have access to the office phone. One resident regularly makes use of this facility. Each individual’s nutritional needs and preferences are properly established as part of the care planning processes and carefully monitored and amended on a day-to-day basis thereon. Staff eat with the residents and eat the same food, which is judged a good quality assurance tool. Staff described how the current manager had introduced a range of healthy eating initiatives. During the site visit, the inspector observed the residents and staff at lunch and judged the meal well prepared and presented. The residents were clearly used to having their meal together and the pace of the meal was unhurried, relaxed and congenial. 94 Whitstable Road DS0000032234.V324241.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 The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The findings from this visit largely confirmed those of the Random Visit in June. Records confirm a comprehensive assessment of needs and preferences in the first instance. The home operates a key worker system, and there was good evidence (anecdotal, observed and records) of personalised routines and interventions to support residents with their self-care skills. All the bedrooms are single occupancy, so that there is scope for residents to meet with visitors, including healthcare professionals in the privacy of their 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 15 rooms, but they are also more usually supported to attend appointments at surgeries and other outlets. This is judged appropriate. The storage and administration arrangements for medication were inspected, and all the current medication administration records appeared to be properly recorded (i.e. no apparent anomalies or gaps) and up to date. Staff had recently received training in medication and it’s administration and this is competency tested (written test) in each case. Each resident’s medication records are prefaced with a sheet bearing their photograph and key information on their medication, what it is for and possible side effects to watch out for. This is judged diligent practice – though some front sheets required better securing against loss or disarray. 94 Whitstable Road DS0000032234.V324241.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 People who use the service are able to express their concerns, and are supported to use the home’s complaints procedure, as required. Residents are protected from abuse, and have their rights protected. EVIDENCE: MCCH has a policy on complaints, which is judged satisfactory, and there is also a picture-assisted version of the complaints procedure to make it more accessible to residents. The home’s register of complaints confirms that residents know who to tell if they are dissatisfied about anything (most usually property maintenance issues). There is currently no active input from independent advocacy services, though MCCH has information on local resources so that arrangements could be put in place. In meetings with the inspector, staff confirmed having had training in a range of pertinent issues such as adult protection, manual handling, and personal safety over the past year, and reaffirmed their commitment to challenge and report any instances of abuse, should they occur. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 17 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. 94 Whitstable Road DS0000032234.V324241.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 enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: 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. There has been extensive refurbishment to this home over the past year and the work has been carried out to a good standard. On the day of this visit, comfortable temperatures and lighting levels were being maintained. All areas of the home were inspected and found to be comfortable and clean. The 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 19 furniture tends to be domestic in style, of a high standard, and there were homely touches throughout. Although there are steep steps into the rear garden, there are handrails to either side and the surfaces, once there, are otherwise reasonably flat (i.e. no outstanding trip or slip hazards) throughout, so that residents can use them with safety. This garden has mature landscaping though this requires tidying up to provide pleasant outlooks from the bedrooms. The home has a “No Smoking” policy. The communal areas of this home are judged spacious. The seating in the dining and lounge areas is uniform in style, but this is appropriate, given all the residents are relatively mobile. The kitchen is light, airy, clean and well maintained, and has benefited by substantial refurbishment. All the WC and bathroom facilities are reasonably accessible to bedrooms and communal areas, and one ground floor bedroom has its own en-suite shower room. But one would need to use the kitchen to access one of the communal WCs, which is not judged a hygienic arrangement. All the bedrooms are single occupancy, so that residents can be assured of privacy. All the bedrooms were inspected and judged well maintained and personalised. They don’t have all the furniture and fittings prescribed by the National Minimum Standard, but their non-provision is properly justified by fully documented consultation and risk assessments. All the maintenance records seen were generally up to date and systematically arranged. A few matters were raised for consideration or attention, to further improve the facilities and level of hygiene. 94 Whitstable Road DS0000032234.V324241.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 adequate 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. But MCCH needs to obtain compliance with the requisite level of NVQ accreditation to meet the National Minimum Standard. EVIDENCE: The staffing arrangements at this home were judged adequate to keep the residents safe and this arrangement includes a senior support worker who can take charge in the event of an emergency. An examination of staffing rotas for the two-week period 22 May to 4 June 2006 indicated that this was representative. Staff are judged generally able to meet most of the day-to-day needs of the residents as long as these needs do not compete. But their scope for one-toone direct support has been raised by staff on more than one occasion as a 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 21 matter requiring attention and review. The loss of MCCH’s Visiting Persons Team after December will provide new challenges and opportunities. There are no ancillary staff, though MCCH has its own maintenance department - support workers are responsible for cooking and cleaning the home. They are to be commended on the level of cleanliness found. Ancillary tasks are detailed on shift planner documents so that anyone authorised to inspect the records can evaluate their scope for direct work with the residents. An assessment of personnel records was not possible, as MCCH has a centralised system for managing the records for its entire group of homes, based at its Head Office at Maidstone. These records are subject to separate auditing arrangements by an officer from the Commission. However, meetings with staff confirmed a robust recruitment process to comply with all the key elements of the standard. Staff have also confirmed that they had supervision sessions, that the frequency of this varied from 4-6 weeks (i.e. in excess of the National Minimum Standard), and that these sessions covered all those elements prescribed by the standard. Staff and pre-inspection documentation confirmed that there is a satisfactory level of investment in mandatory training (e.g. moving and handling, medication, food hygiene, Health and Safety etc) to keep the residents safe. However, only something like 28.5 of staff are currently reported to be accredited to NVQ Level 2 or above. This must be addressed as a priority; in order to maintain parity with expected standards – though the inspector does not judge the residents’ safety and well being are in any way being compromised. 94 Whitstable Road DS0000032234.V324241.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 The management and administration of the home is based on openness and respect, but there needs to be more effective quality assurance systems. EVIDENCE: Ms Karen Loughrill has been the appointed manager of this home since the second week of August 2006 and is reported to have made a very positive impact on staff morale and the running of this home. However, Ms Loughrill was not on duty at the time of this visit to discuss her experience and qualifications. These will be subject to evaluation by the Commission once an application for formal registration is submitted, in due course. The operation of this home will benefit by consistency of management. 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 23 The structure of the overall organisation would appear to offer clear lines of accountability, and generally good use has traditionally been made of the regulatory framework to keep residents safe and to promote their well being. However, MCCH needs to better evidence its compliance with its regulatory duty to carry out its own unannounced inspection visits at least once a month. MCCH has a corporate business plan, but this home needs to set up its own business plan, to reflect local provision and resources – this needs to be linked to quality assurance initiatives and corporate business planning and auditing arrangements, to obtain full compliance with this standard. The interpreted views of residents and feedback from other stakeholders will be crucial to the success of this. The inspector judged the processes for managing this home open and transparent, and judged the delegation of responsibilities within the home appropriate. There was good evidence of residents being supported to make choices on a day-to-day basis. This is a mixed gender team, which reports working harmoniously and flexibly to meet the needs of the residents. The residents all require prompting with their personal care, and the deployment of staff is organised to meet their needs and preferences. Records confirmed regular health and safety audits. The home appeared to be generally very well maintained and hazard free. All maintenance records seen were up to date and systematically stored, so that residents remain safe. 94 Whitstable Road DS0000032234.V324241.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 2 2 X 3 X 4 X 5 2 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 2 33 2 34 3 35 2 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 X 2 3 X X X 3 2 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 4, 5, 6 Requirement Statement of Purpose; Service User Guide; Contract. Copies of the latest versions of all three documents will need to be checked for compliance with the National Minimum Standards Original Timeframe – 31/07/06 And sample copies need to be submitted for the Commission’s reference. Original Timeframe – 31/07/06 MCCH needs to obtain compliance with the requisite level of NVQ accreditation to meet the National Minimum Standard. Action plan to be submitted MCCH needs to better evidence its compliance with its regulatory duty to carry out its own unannounced inspection visits to this home at least once a month. Timescale for action 31/01/07 2 YA5 4, 5, 6 31/01/07 3 YA32 18 31/01/07 4 YA43 26 31/12/07 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 26 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 YA27 Good Practice Recommendations WC / bathroom facilities. The following matters are raised for attention: • The kitchen should not be used as a thoroughfare to WC or continence waste storage facilities • WC / bathroom doors should have double acting locks capable of opened from the outside in an emergency • Paintwork in some areas requires refreshing to obtain a continuous impervious surface (flaking peeling) • Light pull cords should be kept clean External windows should have curtains or blinds to ensure privacy Hygiene. The following matters are raised for attention: • Chipped crockery should be discarded upon discovery • The diffuser on the ceiling light in the kitchen requires replacement • The kitchen should have fly screens on external windows / doors or an insectocutor • The drawers in one freezer were stained, broken or missing and will require attention or replacement • The kitchen 1st Aid kit requires stocking Staffing arrangements should be subject to periodic review to ensure the home maintains its capacity to meet the residents’ assessed needs. 2 YA30 3 YA33 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 27 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 94 Whitstable Road DS0000032234.V324241.R01.S.doc Version 5.2 Page 28 - 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!