Inspection on 05/04/07 for Calcott Bungalow

This inspection was carried out on 5th April 2007.

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

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

Other inspections for this house

Calcott Bungalow 15/06/09

Calcott Bungalow 06/01/06

Calcott Bungalow 07/09/05

Calcott Bungalow 31/03/05

Calcott Bungalow 10/01/05

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 Calcott Bungalow Calcott Sturry Canterbury Kent CT3 4NB Lead Inspector Jenny McGookin Key Unannounced Inspection 5th April 2007 09:30 Calcott Bungalow DS0000023345.V312512.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 Calcott Bungalow DS0000023345.V312512.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. Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Calcott Bungalow Address Calcott Sturry Canterbury Kent CT3 4NB 01227 710196 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) The Avenues Trust Limited Mrs Juliet Morrell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Calcott Bungalow is registered to provide accommodation and personal care for 3 adults with a learning disability and additional challenging behaviour. The registered provider is the Avenues Trust Ltd., which operates a number of homes for people with learning disabilities in Kent and other areas of England. The home is located directly on the A291 in a semi rural area between Sturry and Canterbury in one direction, and the seaside town of Herne Bay in the other, with all the community resources that implies. The home has its own transport, and it is on a main bus route, with further transport links at Sturry and Canterbury, including main line train stations. The home first opened in 1999 and consists of a chalet-style two-storey building, set in half an acre of mature garden, and surrounded by woodland. It comprises three single bedrooms, a lounge and dining room, bathroom, WC, laundry and kitchen facilities. There is also a spacious office and sleep-in area. Access to home and to the car park is to one side of the property through a security gate. The current fees for the service at the time of the visit are £2,379 per week (2206/7 rate still applicable). Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose / Service User Guide. The e-mail address for this home is: calcottbungalow@theavenuestrust.co.uk Calcott Bungalow DS0000023345.V312512.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; to check progress on only one matter raised for attention at the last inspection (January 2006), given the timeframe had run its course; and to review findings in respect of the day-to day running of the home. The inspection process took just under eight hours, and involved meeting with the manager, a support worker, and conversations with two service users. The inspection also involved a complete tour of the premises and the examination of a range of records – most notably personnel files (see section below). One resident’s file was selected for care tracking. Conversations with one of the service users was not possible because of their level of disability, but interactions between staff and the service users were observed during the day. What the service does well: What has improved since the last inspection? The Person Centred Planning process has been used to good effect to explore and support one service user’s readiness to move onto more independent living. He has also been supported with work experience opportunities. Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 6 Another service user is already getting some work experience by carrying out some light domestic chores in an Area Office. “Opportunities” sessions, specifically designed for one service user with special communication needs, have been used with a second service user to support them both to sample and choose options (e.g. tastes, colours, clothes) for themselves. This is, as predicted, helping to redefine their care packages and changing the way staff interact with them, and is judged exemplary practice. Since the last inspection a pigpen has been set up in the grounds of the home, so that one service user could transfer the skills he had learned on Lucketts Farm. The manager has set up a secondary complaints register to record any expressions of dissatisfaction before they turn into proper recordable events; so that anyone authorised to inspect the records can judge the extent to which service users’ views are attended to. This has also served to protect staff against gratuitous comments or allegations made by one service user. Since the last inspection, advocates have been introduced from the Canterbury Advocacy Project, which has an outlet in Herne Bay. Several introductory visits have been made, to try to establish a rapport. The manager personally ensured that all personnel files normally kept at head office were made available to the inspection so that they could be properly audited against the provisions of the National Minimum Standards and regulations. This is in line with the interim arrangement agreed with the service manager at the last inspection. Since the last inspection, a shower and WC have been installed for staff on the 1st floor, so that the service users’ bathroom facilities can be avoided altogether. A hard surface path has been laid between the home and two patio areas, which should improve access, particularly when the ground is wet. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Calcott Bungalow DS0000023345.V312512.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 Calcott Bungalow DS0000023345.V312512.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 excellent This judgement has been made using available evidence including a visit to this service. 1, 2, 5 Prospective residents and their representatives have the information needed to choose a home which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: The home’s Statement of Purpose and Service User Guide show full compliance with the elements of the National Minimum Standard. There are other documents, which are compilations of key information, specifically aimed at the service users, which are picture and symbol assisted to meet their individual needs. None of the three current service users had any choice about their transfer from previous placements, as these decisions were led by the Primary Care Trust, which has a block contract with Avenues Trust Ltd. In two cases the admissions date from as far back as 1999 i.e. predating the provisions of the Care Standards Act and National Minimum Standards. Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 9 However, Avenues has a policy on admissions which prescribes a careful stepby-step process, based on multi disciplinary assessments and meetings, and which is inclusive of the resident’s responses (and their representatives) at every stage. This process was sensitively applied to the third service user, who was admitted to the home in May 2005, and was assessed as exemplary practice at the last inspection (January 2006). This process was again underway, in respect of this particular service user’s move onto more independent supported living arrangements. Although in its early stages, picture assisted sessions have already been used to good effect to identify where he would like to move to. And Person Centred Planning (referred to as PCP from here on) is being used to confirm a multi disciplinary approach and his involvement in each stage. The home is able to demonstrate its capacity to meet the special needs of these residents. Examples are detailed throughout this report. Each placement is confirmed with a contract. Work has also been done to produce a much simplified picture / symbol assisted version of the contract for the service users. Calcott Bungalow DS0000023345.V312512.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 excellent This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Individuals are involved in decisions about their lives and play an active role in planning the care and support they receive. EVIDENCE: The format of the Person Centred Planning is comprehensive and is clearly designed to address the health and social care needs of the individual service users. The care planning processes continue to include specialist input e.g. from the Positive Behaviour Support Team and Community Learning Disabilities Team. Diagrams are used to help these service users (who each have special communication needs) indicate what or who is important to them; what makes them happy / unhappy; and what they enjoy or don’t enjoy doing. At the last inspection the home had recently introduced “Opportunities” sessions, for one service user with special communication needs. This involved him being presented with a modest selection of choices (e.g. cereals, cheeses, Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 11 colours) and being discreetly observed by staff to see if he showed any positive preferences. His capacity to make choices was reported to have already redefined his care package and changed assumptions being made about him. The extension of this principle of working to other experiences and other service users since then is judged exemplary practice. There was good evidence of the home summarising and keeping track of emerging trends - collected in “Active Support” files, there is a range of reporting systems: charts, logs and timetables for activities, behaviour, personal and healthcare needs. And there are practical guidelines on behaviour management. These are used to top up the more formal PCP documentation. There was good evidence of risk assessments in respect of each service user, their activities and the environments they use, on and off site. Key worker meetings are used to evaluate whether the care planning goals set are realistic, achievable and whether the service users are benefiting by their activities. Issues requiring wider of further attention are referred to the team meetings or line management as appropriate. There is a quality audit every year – which this past year has been concentrating on the effectiveness of the person-centred planning processes and this included questionnaires for families and professionals, which is judged an inclusive approach. Avenues Trust has a policy on record keeping, their safe retention and disposal. The home keeps hard copy and electronic records. Files are colour coded and systematically arranged to facilitate access. Cabinets, computers and office facilities are all properly secured. Each resident has a lockable facility to store money and valuables in. Calcott Bungalow DS0000023345.V312512.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 excellent This judgement has been made using available evidence including a visit to this service. 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 individual’s expectations. People who use the service receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-to-day consultation thereon. The home maintains records of activities for each individual, which include scope for their feedback or refusal to participate. Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 13 Service users were observed being supported to make decisions and choices during the inspection visit, and (as found at the last two inspections) appeared to be thoroughly enjoying the range of activities offered to them. This is a home, which makes sure they have fun! One service users proudly showed the many medals he’d won playing football. Another was clearly proud of the two pigs he had been supported to keep in the grounds of the home. This home also offers support to service users in maintaining their practical life skills (clearing or setting tables, gardening, collecting laundry, use of the kitchen as well as self care abilities), and this is underpinned by a comprehensive range of risk assessments and specialist input as appropriate. One service user, for example, is currently responsible for updating one notice board with the date, day of the week and who is shift leader in each case. There are recreational activities both on and off site, and opportunities to access local resources such as shops, seafront, cafes and pubs, swimming, musical events, horse riding i.e. mainstream community activities not confined to or identifiable with disabilities. There is a dedicated vehicle but residents are also supported to use public transport (buses, trains) and to walk. There are open visiting arrangements. There is a telephone line for the residents’ use and one resident has a second telephone point. The other two don’t, however, make or receive any phone-calls. Dietary needs and preferences are also established as part of the preadmission assessment process, and confirmed by the care plan and day-to-day consultation. There was anecdotal information to confirm that individual needs and preferences were being catered for. See also section on “Individual Needs and Choices” for details on “Opportunities” sessions, which are already redefining the service users’ dietary preferences. The dining area is a congenial setting but service users can choose to eat at separate tables, with staff or eat in their rooms. One uses plate guards, but no other adaptations are currently warranted. There is a 4-week cycle of menus, which is changed with the seasons. I joined the residents for lunch out on a sunny patio, and judged the snack well prepared and presented. Records are kept of options actually chosen by individuals, as required. Calcott Bungalow DS0000023345.V312512.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 PCP processes assess the extent to which each service user requires assistance with their own personal care, and their choice and control is actively promoted by staff as far as possible. All the bedrooms are single occupancy and there are enough toilet and personal care facilities to generally guarantee their availability and privacy. Staff are available on a 24 hour basis to assist residents. The PCP process routinely addresses a range of standard healthcare needs e.g. GP, optician, dentist, speech and language therapy etc. Records have been set Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 15 up on file to document access to a range of other healthcare professionals as appropriate All three service users have the same GP, who was chosen and retained for his specialist knowledge, so that the service users’ healthcare needs can be properly met. The medication arrangements were assessed against the provisions of the National Minimum Standards. The storage arrangements were properly secured, and access is restricted to the manager and shift leaders. One service user has agreed to his medication being stored with the others, as a precaution against another service user’s inclination to steal edible things for himself, but is otherwise supported to self medicate. And this has been safeguarded by risk assessment. There were no gaps or anomalies in the Medication Administration Record (MAR) sheets seen. Each service user’s medication records are prefaced with information about the medication, its side effects and contra indications. And the home also keeps a copy of the Royal Pharmaceutical Guidance and British National Formulary to underpin knowledge and practice. Calcott Bungalow DS0000023345.V312512.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 excellent 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 have access to a robust, effective complaints procedure. They are protected from abuse and have their rights protected. EVIDENCE: Avenues Trust has policies on safeguarding adults, complaints and whistleblowing, which have been judged comprehensive. The complaints procedure also has a picture assisted version and CD version to make it more accessible to residents, and will be receiving further development. One meeting with a support worker confirmed feedback from staff at previous inspections – that staff are committed to report instances of abuse should they occur. There have been no registered complaints since the last inspection (January 2006), but the manager has set up a secondary complaints register to record expressions of dissatisfaction before they turn into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which the service users’ responses are listened to and acted on. This has also proved to be a valuable tool for managing gratuitous allegations made by one service user against staff. Since the last inspection, advocates have been introduced from the Canterbury Advocacy Project, which has an outlet in Herne Bay. Several introductory visits Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 17 have been made, to try to establish a rapport, but it may yet be too soon to measure the effectiveness of this. Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 26, 27, 28, 29, 30 The physical design and layout of the home enable people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The location (in terms of access to Canterbury and Herne Bay) and layout of this home are generally suitable for its registered purpose, and measures are in place to minimise the hazards of the busy A291 running alongside the site. All areas of the home were inspected and found to be homely, comfortable and clean. The furniture tends to be domestic in style (no specialist provision is warranted) and there were homely touches throughout. The grounds are reasonably flat although damage by moles (several trip hazards) was observed in the lawned surface. There are several discrete focal areas to draw the attention to, and to sit in, and there is now a path across it, Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 19 to improve access, particularly when the ground is wet. Since the last inspection a pig pen has been set up in the grounds of the home, so that one service user could transfer the skills he had learned on Lucketts Farm, and I was introduced to the two sows he has been tending since they were piglets. The communal areas of this home are spacious. Most windows offer pleasant views of the grounds and surrounding woodland. The seating in the dining and lounge areas are uniform in style, but this is appropriate for the service users. The kitchen is light, airy, clean and well maintained. No matters were raised for attention. There is a communal bathroom / WC on the ground floor and a communal WC on the first floor i.e. reasonably accessible to bedrooms and communal areas. Since the last inspection, a WC and shower facility have been installed on the 1st floor, for staff use, so that the service user’s bathroom facilities can be avoided. No matters were raised for attention. All three bedrooms are single occupancy and one, which would otherwise have been slightly undersize, has been compensated with an adjoining room, which the service user has exclusive use of as a study / lounge. All the bedrooms were inspected and found to be well maintained. In terms of their furniture and fittings, where they were not fully compliant with the provisions of the National Minimum Standards, non-provision is properly justified. Each bedroom was personalised, and each had its own TV and/or sound system. No matters were raised for attention. The upkeep of the bedrooms properly features in the daily routines of the service users, so that their scope for self reliance is promoted. It is a mark of one service user’s success, that his readiness for more independent living is being evaluated. See section on “Conduct and Management of the Home” for findings in respect of house maintenance. Calcott Bungalow DS0000023345.V312512.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 good This judgement has been made using available evidence including a visit to this service. 31, 32, 33, 34, 35, 36 Staff in the home are trained, skilled and in sufficient numbers to support the changing needs of the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing rotas confirmed that are two care staff on the early shift, two or three care staff on the late shift, and one member is care staff on sleeping night duty. 1-2 flexi staff are also available to the home every day. This was judged an appropriate level of staffing, in the light of information on the assessed needs of the residents, and staffing levels complied with this on the day of this inspection visit. An audit of the all the home’s personnel records was undertaken, and this showed a sound level of compliance with good recruitment practice. Each member of staff is required to countersign policies as evidence of having read, understood and agreed to comply with their provisions, to ensure a consistent Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 21 and co-ordinated approach. The home also keeps a copy of the General Social Care Council standards of conduct and practice as a reference document. Key worker sessions are used to evaluate the effectiveness of the care planning process and the relationship between the key worker and resident and issues requiring wider or further attention are referred to the team and/or line manager appropriately A meeting with one member of staff confirmed feedback from staff on previous inspections, that they had supervision sessions, usually monthly, and that these sessions covered all those elements prescribed by the standard: specifically, the translation of the home’s philosophy and aims into work with individuals; monitoring or work with individual service users; support and professional guidance; and the identification of training and development needs. Staff training /competencies were inspected on this occasion, which confirmed information obtained from staff and previous inspections i.e. that there is a satisfactory level of investment. All support staff are reported to be accredited to NVQ Level 2 or above. Only one matter was raised for attention on this occasion. Calcott Bungalow DS0000023345.V312512.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 excellent This judgement has been made using available evidence including a visit to this service. 37, 38, 39, 40, 41, 42, 43 The management and administration of the home are based on openness and respect. The home has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The registered manager has at least three years significant management and supervisory experience and achieved her Registered Managers’ Award, and NVQ Level 4 accreditation in 2006. She has an impressive training record and has demonstrated a commitment to update her knowledge, skills and competencies. The manager’s readiness to be available for advice, support Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 23 and her motivational skills have been singled out as strengths at each inspection visit. The processes for managing the home are accessible, transparent and there are clear lines of accountability within Avenues Trust Ltd. The service manager’s monthly inspection visits (Reg 20) are judged exemplary in their scope and the conspicuous links they make with the National Minimum Standards. The organisation as a whole maintains a proactive overview of organisational issues. Reg 20 reports go to Head Office. Anything outstanding for three months or more is highlighted for attention and there are quarterly overview sessions by the organisation. There is an active business planning process for the home, which sets quality targets, action required in each case, timeframes and links to the corporate business plan. Avenues also has a proactive approach to quality assurance, which places its stakeholders at the centre. See section on “Individual Needs and Choices” for details on the way this principle is being applied on a daily basis, and there are also annual satisfaction questionnaires for families, care managers and funding authorities – the latest ones were studied as part of this inspection visit, and showed a high level of satisfaction with the services provided by this home. Avenues’ key policies have been assessed on previous inspections and have been judged comprehensive in their scope. Staff are required to sign checklists as evidence of their compliance with the policies, which is judged diligent. Avenues Trust has a range of policies governing health and safety matters, which are underpinned by a robust level of investment in training. All the maintenance records seen were up to date and systematically organised, and the home’s Employers Liability Insurance certificate was in the process of being updated, showing the requisite level of coverage. The home’s arrangements for the storage of waste is satisfactory, and its collection properly governed under contract; and the home has a “No Smoking” policy – all of which is designed to keep service users safe. The residents are all white British males. The staff group (which has been very stable for some time) is also predominantly white British but shows an appropriate gender split as well as some cultural diversity from time to time – indicating a commitment to Equal Opportunities in the organisation. Access to activities not necessarily confined to this client group and community presence are central features of the care planning processes and have been reported on elsewhere in this report. Calcott Bungalow DS0000023345.V312512.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 3 2 X 3 4 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 4 3 3 3 3 Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 YA40 Regulation 37 Timescale for action The service manager is reminded 30/04/07 that staff disciplinary matters are events to which the regulatory duty to notify the Commission applies. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 26 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 Calcott Bungalow DS0000023345.V312512.R01.S.doc Version 5.2 Page 27 - 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!