Inspection on 13/09/07 for Betsham Road (84)

This inspection was carried out on 13th September 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Betsham Road (84) 18/05/06

Betsham Road (84) 29/09/05

Betsham Road (84) 20/04/05

Betsham Road (84) 28/10/04

Betsham Road (84) 22/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Betsham Road (84) 84 Betsham Road Erith Kent DA8 2BG Lead Inspector Maria Kinson Unannounced Inspection 13th September 2007 09:30 Betsham Road (84) DS0000037836.V350871.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 Betsham Road (84) DS0000037836.V350871.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. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Betsham Road (84) Address 84 Betsham Road Erith Kent DA8 2BG 01322 332699 01322 332303 betshamroad@mcch.org.uk www.mcch.co.uk MCCH Society Ltd 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) Post Vacant Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (3) of places Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2006 Brief Description of the Service: 84 Betsham Road is managed by Maidstone Community Care Housing Society. The home is situated in a small cul-de-sac in a residential area close to Erith Town Centre. There are bus routes and local shops near by. The home consists of four self-contained flats each with their own kitchen, living areas, bathroom and bedrooms. There is a shared garden at the rear of the property. The service is registered to provide care and accommodation for nine people with a moderate to severe learning disability. The commission was not able to obtain information about the fees charged by this home. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 13th September 2007 and was unannounced. The inspector spent nine hours observing care practices and talking with some of the people that live and work in the home. All of the communal areas and a selection of bedrooms were viewed. Care, medication, money, health and safety and staff recruitment and training records were examined. One health care professional provided written feedback about the service. There were nine people living in the home at the time of this inspection. A random inspection was completed in November 2006. A copy of the report from this visit can be obtained by calling the local area office listed at the back of this report. What the service does well: What has improved since the last inspection? Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 6 There was no evidence that staff were transferring medicines from one container to another. Flat B had been redecorated and refurbished. This included new kitchen units and furniture and fittings. All parts of the home were clean, tidy and welcoming. A new manager had been appointed. This had provided additional stability and support for staff. Unannounced visits to monitor the service were taking place regularly. What they could do better: It was not clear if people were properly assessed before they moved into the home or if the manager had confirmed in writing that the home was able to meet their needs. Some people did not did not know how much they were paying for the service and did not have a written contract. Care records were good but were not always reviewed regularly or updated when people’s needs or circumstances changed. The management of medicines was mostly good. Some medicines that were left over from the previous months supply were not recorded on the new medication chart and storage temperatures were not monitored in all of the flats. Most people were supported to lead active and fulfilling lives but a few people did not have regular opportunities to go out. Staff did not keep adequate records about the checks that they had undertaken when recruiting new staff. Daytime staffing levels were good but some staff were concerned that the night carer did not have adequate support. The off duty roster did not include all of the staff that worked in the home. Fire safety arrangements were good but fire drills did not take place regularly. Equipment was serviced and inspected but it was not clear if any action was taken to address the concerns raised in the mains electricity installation report. One strategy that was used by staff to keep people safe was not recorded. There were some systems in place to monitor the quality of the service but this did not include consultation with people’s relatives or representatives. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for supporting people to settle into the home were good but there was little evidence that people’s needs were fully assessed before they moved in. EVIDENCE: The manager said that the homes Statement of Purpose and Service User Guide had recently been updated. The manager was advised that CSCI must be notified about changes to these documents. The manager agreed to send a copy of the new documents to the commission. Three new people had moved into one of the flats in the home since the last inspection. Staff said that various meetings and assessments had taken place prior to the move. There was little written evidence to support this. A ‘Positive Futures’ plan was seen for one of the people that had moved into the home. It was not possible to establish when the plan was completed as it was not signed or dated and there was no reference the type of environment or facilities the person would require. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 10 One of the people that had moved into the home disliked having a shower. The only facility provided was a shower. It was not possible to establish if the persons needs and preferences in respect of bathing were assessed prior to the move. The kitchen and dining area in the flat were open plan. This meant that the people living in the flat were able to move freely between the kitchen and dining area. In the persons previous placement access to the kitchen was restricted for health and safety reasons. Staff had placed a heavy chair at the entrance to the kitchen to try to stop people from going into this area when they were not in the room. It was not possible to establish if this issue was assessed before the person moved into the home. See requirement 1. A considerable amount of work had been undertaken to ensure a smooth transition for the new people that had moved into the home. All three people had lived together in another home prior to their transfer to Betsham Road. Staff said that it was decided after discussions with the service users and their representatives that they would like to continue living together. Some of the staff from the previous home transferred to Betsham Road for a period to help them to settle into their new environment and to ensure that their usual routines were maintained. Some but not all of the people living in the home had received a written contract. The contract provided clear information about the service and pictures to assist some of the people using the service to understand their rights and responsibilities. The contract did not include information about fees and was not agreed or signed by the service user or their representative. See recommendation 1. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff identified people’s needs and preferences and used this information to provide personalised support. People were supported to undertake activities that they enjoyed even when this involved potential risks. EVIDENCE: The care records for two people living in flat B and D were examined. The files included information about how the person liked to be addressed, their preferred routines, how they communicated and the types of activities they liked and disliked. Some of the information in support plans was out of date. For instance the plan for a person that had recently moved into the home indicated that they liked long baths. The plan had not been reviewed and updated to indicate that staff could no longer support the person to have a bath, as this facility was not provided. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 12 Plans also provided information for staff about peoples likes and dislikes and the type of environment that staff should promote within the home to meet the person’s needs. For one person this included the need for peace and quiet and regular outings to local parks. Guidance was provided for staff about managing challenging behaviour and ensuring effective communication. The information provided for staff was good. Individual needs were identified and personal choice and independence were promoted. Staff should ensure that plans are reviewed and updated when people’s needs change. See recommendation 2. It was clear that people using the service, including people with communication difficulties were supported to make personal choices. Records showed that people stated who they wanted to attend their care planning meeting, about what food they wanted to eat, what items they wanted to purchase and decided where they spent their time in the home. Assessments were completed for people that undertook activities that were considered by staff to involve some degree of risk. Risk assessments were completed for individuals who liked to go swimming, used the bathroom independently and had challenging behaviour. Staff should ensure that assessments are reviewed regularly. See recommendation 3. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most people were supported to undertake activities and attend events that they enjoyed. A varied range and choice of food was provided to meet people’s needs and tastes. EVIDENCE: Each person had a weekly activity planner. The planners provided information for staff about where people were and what activities they should be doing on certain days. Some of the people living in the home attended local day care services where they learnt new skills. A number of people liked to attend social clubs and events during the evening and some people spent time outside the home with their relatives or staff. The activity planner for one person indicated that they would be supported to take local walks and would go out for half a day once a week. There was no Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 14 evidence in the persons records that any of these activities had taken place in recent weeks. However the person had spent time watching television, listened to music and played with some of their personal possessions. Staff said activities had been put on hold whilst the person settled into his new environment. The diary for the other person indicated they had attended cooking classes at the day centre, listened to music, organised a party, assisted staff by washing the dishes, completed arts and crafts activities and spent time shopping. On the day of the inspection one person had spent the day with their relatives. Staff supported the person to prepare for the visit and accompanied them on the journey to and from the family home. The minibus that was used for some outings was broken. Staff said that a new bus was about to be purchased from an amenity fund. The deputy manager was making the arrangements and had completed a test drive in the new vehicle. The menu was examined in flat B. Staff developed the menu with suggestions from one person who was able to tell staff what they liked to eat. The menu was varied and nutritious. The records showed that the three people living in this flat often ate different dishes because they did not like the food listed or wanted something different. Betsham Road (84) DS0000037836.V350871.R01.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 good. This judgement has been made using available evidence including a visit to this service. Staff worked in partnership with other professionals to meet people’s health needs. The management of medicines was good but storage temperatures were not monitored. EVIDENCE: Staff had recorded people’s individual preferences and usual routines. Some of the people using the service said they liked to get up a little later when they were not attending the day centre and liked to do things a little slower on these days. Staff knew what people liked and disliked and tried where possible to accommodate people’s preferences. Staff said that one person liked to have breakfast and then return to their bedroom for a period. Although this person had limited verbal communication they were able to advise staff when they were ready to wash and dress by getting their toiletries out. Records indicated that health issues were monitored and staff arranged for the people living in the home to see their GP when they were unwell. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 16 A personal health profile was compiled for each person. The profile provided information for health care professionals about the persons medical history, medication, communication needs and signs that that may indicate that they were unwell. Some information such as the person’s home address required updating. One health care professional provided written feedback about the service. The person stated that they had established a good working relationship with staff from the home and had always found staff “helpful and willing to support service users”. The person also stated that staff usually had the right skills to meet people’s healthcare needs. Staff had started to update people’s communication passports. This document provides useful information for care staff and other professionals about the persons preferred method of communication. Two medication charts were examined in flat B and D. Records of receipt, administration and disposal of medicines were satisfactory. Medication charts showed that people were receiving their medication regularly and all of the medicines listed on the chart were in stock. Staff must record medication that is left over from the previous months supply on the new medication chart. This will make it easier to account for all medicines. Medicines were stored in a filing cabinet in the lounge in one of the flats. This was not ideal but discussions with staff indicated that there were no other suitable areas in the flat that they could use. The room temperature was not monitored so it was not possible to assess if medicines were stored at a suitable temperature. See requirement 2. Betsham Road (84) DS0000037836.V350871.R01.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 good. This judgement has been made using available evidence including a visit to this service. There were procedures in place to protect people from abuse and to address complaints and concerns. EVIDENCE: The home had a comprehensive complaints procedure, which included a timescale for responding to concerns and contact details for the commission. The home had not received any complaints in the period since the last inspection. The money records for two people were checked. Adequate records were maintained about people’s personal money. Records showed that people were able to purchase items that they liked. Receipts were kept for most purchases. Staff had access to safeguarding adult’s procedures. The procedure advised staff to notify social services and CSCI about allegations of abuse. Staff said they had attended protection of vulnerable adults training and some were due to attend an update later in the year. Staff said they would report concerns or allegations to senior staff or the on call person and would record information in the person’s notes. One allegation was referred to the local authority in November 2006. This issue was investigated but was not substantiated. Betsham Road (84) DS0000037836.V350871.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): 24, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained to a satisfactory standard and all areas were clean, tidy and comfortable. EVIDENCE: The home was maintained to a satisfactory standard. No significant health and safety issues were identified. Since the last inspection work had been undertaken to provide a patio area in the garden and to redecorate and refurbish flat b. The work included laying new flooring, fitting new kitchen units and purchasing new equipment and furniture. The three people that moved into this flat bought their own personal items and some of the furniture from their previous home with them. The flat looked clean, comfortable and welcoming. One person that moved into the home in April 2007 disliked showers. The ‘essential’ information recorded for this person stated that they liked to have a Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 19 bath at 7am each day. The flat that this person was living in did not have a bath. Staff had identified that the bathing facilities did not meet this persons needs and had arranged for an occupational therapist to visit the home to complete an assessment. A surveyor was also due to visit the home to consider whether it would be possible to fit a bath. As the person concerned had little verbal communication and was not able to make their views known an advocate had been appointed to ensure that the issue was addressed to the persons satisfaction. See standard 2. All parts of the home were clean tidy and odour free. An inspector from the local authority environmental health department had visited the home in September 2007. The manager said cleaning schedules had been developed for all of the flats as a result of this visit. Refrigerator temperatures were not always monitored by staff. See recommendation 4. Hand washing facilities were mostly good. The manager was awaiting the findings from a recent infection control audit. Betsham Road (84) DS0000037836.V350871.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): 32, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels were good overall but some concerns were raised about the vulnerability of the night duty carer. Staff had access to relevant training and were supported to gain recognised qualifications. Staff recruitment procedures were known to be good but could not be verified due to a lack of records. EVIDENCE: 75 of care staff had attained a vocational qualification in care at level two or above. This exceeds the standard set by the Department of Health. It was apparent that the home had struggled to maintain regular supervision, and staff meetings during the period when there was not a permanent manager in post and there was a shortage of senior staff due to illness and leave. The new manager had started to address some of these issues. The off duty roster indicated that there were usually five staff on duty during the day and one member of staff overnight. Staff said that staffing levels were satisfactory but expressed some concerns that there was only one member of Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 21 staff on duty during the night. The manager said that an additional member of staff was on duty between 9 -12pm to provide ‘one to one’ support for one person. There had been one incident outside these times when the staff member on duty required support. Fortunately this incident occurred as the day staff were coming on duty. The Residential Forum recommend that where people have behaviour that challenges there should be two members of staff on duty. See requirement 3. The off duty roster did not include the managers shifts and was not dated. See recommendation 5. The commission had agreed with the Registered Person that staff recruitment records could be held centrally if a form outlining all of the information and checks that were undertaken in respect of staff was kept in the home for inspection. Two forms were examined. The agreed form was in use but was only partially completed for one member of staff. See requirement 4. A provider relationship manager from CSCI was undertaking some additional checks at the company’s head office. The most recent audit was undertaken in January 2007 when all of the files examined were found to comply with regulations. Staff had access to a comprehensive programme of training. During the past year some members of staff had attended fire safety, medication, moving and handling, epilepsy, health and safety, care planning and COSHH training sessions. Staff said that “training was always there” and commented that “MCCH invests” in good quality training for staff. The manager had arranged an away day for staff, which will include a challenging behaviour training session. One person living in the home had a sensory impairment. Staff said that this person could make their wishes known but felt that ‘signing’ training would be useful. See recommendation 6. The company provides a comprehensive induction programme that includes first aid, medication, moving and handling, fire safety, food hygiene, health and safety, infection control and adult protection training. During the first twelve weeks staff were expected to complete a workbook that covered all of the common induction standards. Betsham Road (84) DS0000037836.V350871.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): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People said that they liked living in the home and were happy with the way things were organised. Some work was taking place to monitor the quality of the support provided in the home but this did not include consultation with people’s representatives. The home was well maintained but strategies to promote peoples safety were not always recorded. EVIDENCE: A new manager had been appointed since the last inspection. The new manager said she had experience of managing services for older people and had worked with people with learning disabilities in the past. The manager told the inspector that she had completed the registered managers award and Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 23 had a NVQ level four in care. The manager was advised to submit an application to register with the commission. The new manager had written to relatives to introduce herself and to advise them about management changes. The new manager had spent some time getting to know the people using the service and staff and was now familiarising herself with local policies and procedures and records. Staff said the new manager was approachable and listened to their views. Some quality monitoring was taking place but this did not include feedback from service users relatives or other professionals. Staff completed regular ‘walking route’ checks to assess health and safety and maintenance issues and a weekly returns form was completed by the manager to provide information to senior staff about significant events. Unannounced visits were taking place more frequently and a healthy living audit was planned. See recommendation 7. The fire risk assessment was reviewed in 2006. Fire safety equipment was tested and serviced at regular intervals. There had been two fire drills in the past ten months, one of which involved some of the night staff. The records for the last fire drill indicated that there was a “slow response”. It was not clear if any action had been taken to address this issue. Fourteen staff had attended a fire safety training session in 2006. See recommendation 8. Health and safety records were sampled. All of the records excluding the mains electricity installation report were found to be satisfactory. It was not clear what action, if any was taken to address the mains electricity installation, which was reported to be “unsatisfactory”. See requirement 5. Staff had placed a heavy chair at the entrance to the kitchen in flat b. Discussions with staff indicated that this had been undertaken to maintain peoples safety. Staff said the people living in the flat had restricted access to the kitchen in their previous placement due to health and safety concerns. See requirement 6. Betsham Road (84) DS0000037836.V350871.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 2 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 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 2 X Betsham Road (84) DS0000037836.V350871.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 YA2 Regulation 14 Requirement Timescale for action 26/11/07 2. YA20 13 3. YA33 18 4. YA34 19 The Registered Person must not admit a person into the home unless: • The persons needs have been properly assessed • The Registered Manager has confirmed in writing to the service user that the home can meet their needs The Registered Person must 26/11/07 ensure that ‘left over’ medication is carried forward onto the new MAR chart and that medicines are stored at a suitable temperature. The Registered Person must 26/11/07 carry out a risk assessment regarding night staffing levels. The assessment must take into account peoples special needs and health and safety issues. A copy of the assessment must be forwarded to the commission. The registered person must 23/12/07 ensure recruitment information kept in the home provides evidence to show staff are recruited in line with the requirements of this regulation. DS0000037836.V350871.R01.S.doc Version 5.2 Betsham Road (84) Page 26 5. YA42 23 6. YA42 13 Repeated requirement. The previous timescales of 14/07/06 and 27/11/07 were not met. The Registered Person must advise the commission in writing about the action that was taken to address the concerns identified in the mains electricity installation report. The Registered Person must carry out a risk assessment in respect of access to the kitchen in flat b. 23/12/07 26/11/07 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 YA5 Good Practice Recommendations The Registered Person should ensure that each person has an individual written contract. The contract should include information about the fees charged by the service and should be agreed and signed by the service user or their representative. The Registered Person should ensure that support plans are reviewed and updated when peoples needs or circumstances change. The Registered Person should ensure that risk assessments are reviewed and updated regularly. The Registered Person should ensure that refrigerator temperatures are monitored and maintained at the recommended level. The Registered Person should ensure that the off duty roster includes all of the staff that work in the home and is dated so that it is clear what period it relates to. The Registered Person should provide ‘signing’ training for staff that work in flat D. The Registered Person should obtain feedback from the people using the service and their representatives about the home. This information should be used to improve the service. The Registered Person should consider increasing the DS0000037836.V350871.R01.S.doc Version 5.2 Page 27 2. 3. 4. 5. 6. 7. YA6 YA9 YA30 YA33 YA35 YA39 8. YA42 Betsham Road (84) frequency of fire drills and monitor staff responses to drills. Betsham Road (84) DS0000037836.V350871.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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