Inspection on 06/12/07 for Amherst Court

This inspection was carried out on 6th December 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Amherst Court 25/11/08

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Amherst Court 39 Amherst Road Bexhill-on-Sea East Sussex TN40 1QN Lead Inspector Joseph Harris Key Unannounced Inspection 6th December 2007 10:00 Amherst Court DS0000069585.V350445.R02.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 Amherst Court DS0000069585.V350445.R02.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. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amherst Court Address 39 Amherst Road Bexhill-on-Sea East Sussex TN40 1QN 01424 217622 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) Pages Homes Ltd Vacant Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0) of places Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 15. Date of last inspection Brief Description of the Service: Amherst Court is a home for up to 15 people with enduring mental health issues. The house is located on a residential street approximately ½ mile from Bexhill town centre. There is street parking available outside the home. The accommodation is over 4 floors. The basement contains all of the communal space, which consists of a large lounge/diner, kitchen, laundry and an office. There is a small garden to the rear, which has a summerhouse used as a smoking room. The upper floors in the home consist of bedrooms and bathrooms/toilets. The current fees range from £450.00 to £750.00 per week. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection process culminated in a site visit to the home on 6th December 2007. The site visit commenced at approximately 10am and concluded at 5.30pm, lasting for around 7.5 hours. During the course of the visit a tour of the premises was undertaken and discussions were held with the owner, manager, staff members and service users. A range of documentation was examined relating to the residents, staff, medication, health and safety and the day-to-day running of the home. The home also returned the Annual Quality Assurance Assessment (AQAA), which provides information to inform the inspection process. What the service does well: What has improved since the last inspection? What they could do better: 9 requirements and 9 recommendations have been made as a result of this inspection process. A number of issues raised are considered as a priority for the registered provider, most notably the development of care plans for each service user, incorporating risk assessments. A number of confidentiality issues were raised throughout the site visit that also require urgent attention. Other requirements included the development of robust recruitment and quality assurance Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 6 processes. The review and updating of policies and procedures, the statement of purpose and service user’s guide. A number of institutional and restrictive practices were noted during the inspection that also need to be addressed. Amongst the recommendations for best practice were topics including activities and support in the community, updating daily notes and healthcare records, developing the pre-admission needs assessments, providing structured supervision to the manager and reviewing appointee arrangements. 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. Amherst Court DS0000069585.V350445.R02.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 Amherst Court DS0000069585.V350445.R02.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): 1 and 2. Quality in this outcome area is adequate. Prospective service users are at a disadvantage in that they only have a limited amount of information available to them regarding the home. Individual needs are assessed although this process could be further developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose and service user’s guide in place, however the copies examined were both developed by the previous owner and manager of the home. Many of the facilities and services remain the same from the previous ownership and therefore much of the information remains relevant. These documents do need to be updated reflecting information including the changed ownership, management and aims of the service. The updated service user guide should be written clearly and provided to all current, new and prospective service users. Refer to requirement 1. There have been no new admissions for since the last inspection therefore it was not possible to ascertain precisely the process for pre-admission Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 9 assessment. However, adequate assessment information was in place within the service user files examined and the manager stated that for the time being she intends to maintain the current system. Care Programme Approach (CPA) care plans, risks assessments and background information was available. The home has a pre-admission assessment format in place, although this would benefit from review ensuring that information gathered is pertinent to the needs and aspirations of service users. Refer to recommendation 1. Amherst Court DS0000069585.V350445.R02.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): 6, 7, 8, 9 and 10. Quality in this outcome area is poor. Individual needs are regularly reviewed, but there are inadequate plans of care and support in place. Residents have restricted choice in a number of areas of their lives and have limited participation in the home. Risk assessments need to be developed in a more robust fashion. Information about service users is not handled confidentially. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inherited system of care planning and needs assessment requires a thorough review. With the exception of CPA documentation there were no clear individual plans in place in any of the three service user files examined. However a monthly report is carried out, which updates key areas of care and support for each resident. The individual files contain a lot of information that could be archived making the information more targeted and easily accessible. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 11 The plans contain minimal guidance for staff to assist residents in meeting their needs or in relation to perceived risks. An individual plan of care needs to be developed for each service user focusing on their needs, aspirations and short/long term goals. Refer to requirement 2. Additionally risk assessments need to be completed for all service users clearly addressing individual risk factors and providing clear guidance for staff to support residents in minimising these risks. Refer to requirement 5. Service users should also be involved as fully as possible in being included in the development and review of these issues. There are a number of strict rules and routines in place that diminish the choices that residents can make about their lives. These include times for getting up, going to bed and lights out. Some residents also have restrictions in place regarding their tobacco usage. In discussion with the manager it was stated that these restrictions are in place generally for the needs of the minority of residents, but are applied to all in the home. Where restrictions are required to benefit the health and welfare of individual service users these should be discussed and agreed through the multi-disciplinary team with the involvement of the resident concerned. Refer to requirement 3. The home takes on an appointee role for some service users. This arrangement needs to be reviewed and, ideally, should be taken on by someone independent of the service such as a care manager. Where this is not possible, individually arranged bank accounts need to be set up ensuring that clear records are maintained of all incoming and outgoing transactions for auditing purposes. Refer to Recommendation 2. Service users are required to take a role in the upkeep of the household completing chores around the home. However, this is managed in a rather institutional manner. Staff clean residents’ rooms on a daily basis and residents have to clean their own rooms every Friday morning including changing the sheets. There are also rotas in place for household chores. These routines were discussed with the appointed manager and it was advised that other systems should be considered encouraging more personal responsibility and independent living skills. A number of service users did express some dissatisfaction around the routines in the home. “I don’t like having to go to bed at 10 o’clock. Also I have to clean my room every Friday”, were among the comments made by some service users. Refer to requirement 4. Regular residents meetings are held covering a range of topics. Throughout the course of the inspection a number of issues were raised regarding the confidentiality of information held about service users. The current practice in the home is to write up all daily notes on a laptop computer situated in the lounge. There were no passwords or security measures in place to protect this information from general use. Additionally a number of notices had been put up around the home containing sensitive information. The cupboards in the lounge that contain service user files and other confidential information have poor security and can easily be opened without a key. In Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 12 contrast, the staff in the home do not have access to the office when the appointed manager is not in the home and must complete all records and take telephone calls in the communal areas of the home presenting potential breaches of security and confidentiality. The home must review and improve measures ensuring confidentiality. Refer to requirement 6. Amherst Court DS0000069585.V350445.R02.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): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. Service users are able to take part in the local community and access mental health resources. There are recreational and leisure activities available to those who wish to take part. A healthy, balanced diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are a number of activities available to service users outside the home within the local community. One resident has a part-time job and other individuals attend community mental health resources. There is little in the way of structured activity in the home, although residents are free to plan their time as they wish. Many residents go out individually or in small groups going into the nearby town. Staff were observed to interact with service users, although the majority of their time is concentrated around housekeeping duties and routines of the home. It is acknowledged that there are benefits from Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 14 maintaining a structure to the day, but a balance needs to be struck between this and providing support to service users. One staff member said, “we spend too much time cleaning and not enough time working 1:1 with residents.” Refer to recommendation 3. It was reported that visitors are welcome to visit the home at all reasonable times during the day. No visitors were available to speak to throughout the course of the site visit, however service users confirmed that this was the case. The home has a relatively strict routine, especially concerning housekeeping tasks and times for getting up and going to bed. Although there is some benefit from promoting residents’ involvement in the day-to-day running of the home this could be managed in a more flexible manner with the emphasis on developing individual independent living skills rather that the needs of the home. Some residents said that they feel like they have to go out for a walk every day regardless of whether they want to or not. The manager stated that this is not the case, but there is possibly an issue of perception and/or communication between staff and service users. Refer to requirement 4. All residents spoken to said that the quality of food in the home is good. They stated that there are choices at each mealtime and that residents have some involvement in the planning of menus. There is a domestic style kitchen with a serving hatch into the dining area. The dining room is suitably spacious and can comfortably accommodate all residents. One resident said, “the food is very good, no complaints there!” Menu records show that a healthy and balanced diet is provided and there were adequate food stocks to ensure that the food on the menu could be cooked. The home employs a cook throughout the week. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. Service users receive personal support appropriately, however daily recording and support plans need attention. Healthcare issues are managed although recording and monitoring could be improved. Medication is safely administered and recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The main focus of providing support with personal care issues is solely encouragement from staff. All of the service users in the home are self-caring. However, consideration should be given to the development of support plans clearly identifying the areas and nature of support that is required. These should also include the strengths of individual residents and promote independent living. Refer to requirement 2. The home currently completes daily records on a laptop computer using a cumbersome and lengthy document. Aside from confidentiality issues as previously mentioned, the format for these daily notes should be reviewed to ensure easier tracking of Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 16 information and more focused reports detailing the activities, achievements and issues of each day. Refer to recommendation 4. All residents receive healthcare support from their GP and, in the majority of circumstances, local community mental health teams and social services. Service users generally attend appointments independently, but staff provide support as and when required. Most residents have a CPA review 6 monthly or annually involving the multi-disciplinary team and attend appointments with their psychiatrist. The home retains appointment letters and records healthcare developments. However, it is advised that a stand alone healthcare monitoring form is developed recording the nature of an appointment and any relevant outcomes such as medication changes or other healthcare advice. Refer to recommendation 5. The home manages medication issues well. A community pharmacist visits the home every 6 months providing guidance and advice. A medication issue involving one service user was identified over recent months, an initial investigation by the care manager has suggested that the home did not contribute to the error, but was a miscommunication between the prescribing doctor and the pharmacy. However this incident is still subject to an on going investigation by the local NHS Trust. Medication administration records are clear and well maintained. Storage facilities are suitable for the needs of the home and records are maintained of the receipt, return and disposal of medications. Staff administering medication are provided with adequate training and the manager has completed an advanced medication course. None of the residents at the present time are self-medicating, although this should be an area for further development in the future. There are suitable policies and procedures in place covering the salient aspects of the medication process. The home was advised to purchase an up to date BNF or similar medication publication. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. Service user views are listened to, although greater efforts could be made to include residents in the organisation of the home. Service users are protected from forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure, which would benefit from being updated under the new ownership. However, residents have suitable opportunities to raise any issues about the home and stated that they felt comfortable approaching the manager and staff. Regular resident meetings are also held providing an outlet for individuals to influence issues in the home. A number of issues were raised throughout the site visit by various residents voicing some dissatisfaction at a number of the routines and rules in the home. The manager was made aware of these issues and is advised to develop strategies to promote open and frank discussion surrounding issues of concern and complaint. The home has policies and procedures in place regarding adult protection and abuse, although they would benefit from being updated by the new owner. All staff receive instruction through the induction process and external training in adult protection issues. The manager is also a trained trainer in adult Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 18 protection and demonstrated a good understanding of the reporting, recording and signs of abuse. There have been no adult protection alerts raised since the last inspection. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is adequate. Service users benefit from living in an environment that is suitable for their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Amherst Court is a four-storey terraced house on a residential street close to the centre of Bexhill. There is street parking outside the home. The communal accommodation is all located on the basement floor of the house with a large lounge/dining room being the main room. There is a summer house in the garden which is used as a smoking room. The office is sited off the lounge as is the domestic style kitchen. There is a small, cramped laundry area, but this is being relocated to an outbuilding and should provide a more useful space. There are toilets on each floor and showers or bathrooms on the top 3 floors. The shower on the ground floor is quite difficult to access and the showerhead Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 20 would benefit from cleaning to ensure better water coverage. The majority of bedrooms are single occupancy, although there are two double rooms. Residents sharing these rooms are happy to do so at the present time, but should the occupants change then expressed agreement should be sought from the relevant service users. There are some storage cupboards in the lounge housing sensitive information that, although lockable are not secure. Consideration should be given to preferably relocating this information into the office with the staff member in charge having access at all times or replacing the cupboards. Refer to recommendation 7. None of the bedrooms were viewed by the inspector, but all service users spoken to said that their rooms are suitable for their needs and that they can personalise them as they wish. On the day of the site visit the home was clean, hygienic and free from offensive odours. Hazardous substances are stored appropriately. It was reported that the home meets the requirements of the fire and environmental health departments. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 21 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): 32, 33, 34 and 35. Quality in this outcome area is adequate. Service users are supported by suitably trained and competent staff in adequate numbers. Recruitment processes need to be reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Over 50 of the care staff team have achieved an NVQ level 2 or above and further staff have been enrolled on this course. Staff spoken to appeared to have a good understanding of the needs of the service users, but stated that without effective care planning processes the delivery of support is dependent on the individual abilities of staff. There are a minimum of 2 staff on duty throughout the day, although this can, according to past duty rotas, rise to 3 or 4 staff on some days including the manager. At night there is one member of sleep-in staff on duty. The staffing numbers are adequate for the needs of the home, although should be kept Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 22 under review, particularly at night dependent on the needs of the service users. It was also recommended that the duty rota is updated to ensure all staff and manager hours are included. The rota should also state the full name of staff and their position in the home. Refer to recommendation 8. The manager and owner reported that all mandatory training is provided to staff within the first 6 months of employment. This was difficult to evidence as there is no training matrix in place. Staff files examined did however contain certificates of training providing some evidence that this training has taken place. Additional training has been provided covering topics such as mental health and diabetes. The owner stated his intention to keep providing training and promote staff development. The home has introduced the Common Induction Standards to run alongside the home’s own induction process. 2 staff personnel files were viewed, which contained all relevant information with the exception of application forms. All applicant details are gathered at the interview stage and prospective employees currently do not complete a formal application form. The home must ensure that all applications for work are considered following the completion of an application form containing a full employment history, reasons for leaving and a declaration of any offences. Refer to requirement 7. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is adequate. The appointed manager possesses the qualities to run the home well although the ethos of the home could be more inclusive and the quality assurance processes more robust. Policies and procedures require review and updating. The health, safety and welfare of service users is protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The appointed manager has been in post for approximately 2 months but is not yet the registered manager. She had acted for a number of years as the deputy manager and possesses the knowledge and experience of the home necessary to fulfil her role. The appointed manager is, however, quite Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 24 inexperienced in this new role and would benefit from regular and focused supervision from the registered provider in order to develop into the position. Refer to recommendation 9. The ethos of the home requires some development as previously described within the report. This should focus on the inclusion of staff and service users in the day-to-day running of the home and the development of the service. Attention should be paid to the strict rules and routines in the home moving away from an institutional approach to one that encourages and supports service users to develop independent living skills. Refer to requirements 3 and 4. The registered provider visits the home at least on a weekly basis and conducts monthly monitoring visits, although copies of these records were not available to view and should be retained in the home. The quality monitoring processes need to be further developed over the coming months to include satisfaction surveys for service users, relatives, staff and professionals. This information should be used to formulate an annual quality report demonstrating how any issues raised are to be addressed. Refer to requirement 8. Policies and procedures are in place covering all required topics, however the vast majority of these have been inherited from the previous ownership of the home and need to be reviewed and updated reflecting the changed ownership and management of the service. Refer to requirement 9. All documents relating to the health, safety and welfare of service users were seen to be up to date including fire safety records, accident records and service/utility maintenance certificates. Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 25 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 2 1 1 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 2 2 2 X 3 X Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 26 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5 Requirement To ensure that an up to date, clear and accessible service user’s guide and statement of purpose are available for all prospective service users. To develop individual service user plans providing clear guidance for staff to meet needs and aspirations. To ensure that any restrictions in place are for the benefit of individual service users and are agreed through multi-disciplinary team processes. To encourage and enable service users to take a more pro-active role in the day-to-day running of the home promoting individual living skills and personal responsibility. To develop clear and robust individual risk assessments addressing all perceived risks and providing unequivocal guidance for staff. To ensure all sensitive and personal information is kept in a confidential manner at all times. To ensure all applications for employment are accompanied by DS0000069585.V350445.R02.S.doc Timescale for action 01/02/08 2. YA6 YA18 YA7 YA38 15(1) 01/03/08 3. 12(3) 01/02/08 4. YA8 YA12 YA38 24(3) 01/02/08 5. YA9 13(4) 01/02/08 6. 7. YA10 YA34 17 19, schedule 01/01/08 01/02/08 Amherst Court Version 5.2 Page 27 2 8. YA39 33 a completed application form. To develop robust quality assurance processes including a range of satisfaction surveys and an annual quality report. To review and update policies and procedures. 01/03/08 9. YA40 17 01/03/08 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. 2. Refer to Standard YA2 YA7 Good Practice Recommendations To develop robust pre-admission needs assessment processes. To review appointee arrangements for individual service users and implement appropriate safeguards where this role cannot be taken on by someone independent of the service. To support service users to explore a range of available activities and promote greater staff support in this respect. To review and update the format for recording daily records detailing the activities of service users. To review and update the method for recording healthcare information and monitoring. To purchase a BNF or similar medication publication. To relocate information stored in the lounge to the office or improve security of these cupboards. To ensure all showers are in full working order. To ensure an up-to-date and complete duty rota is available at all times. To provide structured supervision and support for the manager and for her to progress through the fit person’s process with the Commission for Social Care Inspection. 3. 4. 5. 6. 7. 8. 9. YA12 YA18 YA19 YA20 YA24 YA33 YA37 Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 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 Amherst Court DS0000069585.V350445.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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