Inspection on 06/01/06 for Calcott Bungalow

This inspection was carried out on 6th January 2006.

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

The inspector found 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 05/04/07

Calcott Bungalow 07/09/05

Calcott Bungalow 31/03/05

Calcott Bungalow 10/01/05

Similar services:

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Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

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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 Unannounced Inspection 6th January 2006 09:55 Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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.V277006.R01.S.doc Version 5.1 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.V277006.R01.S.doc Version 5.1 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.V277006.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 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. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was used to check progress with matters raised from the last inspection (September 2005,) accepting that a number of timeframes had run their course; and to reach a preliminary view on other aspects of the day-to day running of the home not assessed at the last inspection. The inspection process took just over five and a half hours, and involved meetings with one resident, the service manager, senior support worker and a member of the Avenues Bank staff. The registered manager was not on duty that day. The inspection also involved an examination of records and policy documents and the selection of one resident’s case file, to track his care. All areas of the home were checked for compliance with the National Minimum Standards, and interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? With one exception (access arrangements to recruitment documentation), all matters raised by the last inspection – required and recommended action have been addressed. This is judged a very satisfactory use of the inspection process. The introduction of “Opportunities” sessions for one resident with special communication needs, to support him to sample and choose options (e.g. tastes, colours) for himself is already reported to be redefining his care package and changing the way staff look at him. This is judged a very positive Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 6 development, and its extension to other residents and other options promises to set exemplary standards. 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. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 1. The homes’ Statement of Purpose and Service User Guide are now fully compliant with all the elements of this standard, which means that service users, their families or representatives as well as funding authorities have all the information required to make appropriate decisions about placements. 2. Residents did not have any choice over their admission, but the decision to place them at this home was based on full multi—disciplinary assessments, which involved the residents at every stage. 3. The home is able to demonstrate its capacity to meet the assessed needs of individuals it admits. 4. Avenues Trust Ltd. has a careful admission process, designed to enable the prospective resident to sample the facilities and activities provided by the home, before their admission is confirmed. This process includes visits, overnight stays and a trial period. The manager’s extra documentation has been judged an exemplary gesture. 5. Each resident’s placement is subject to a documented contract, There is now also a draft contract available in a format more suitable for the residents Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 9 EVIDENCE: Copies of the most recent Statement of Purpose and Service User Guide were supplied for inspection, and have been amended to obtain full compliance with the elements of the National Minimum Standard. There are similar compilations of other documents aimed at service users, their representatives (familial or professional and staff), with all the variations in presentation and scope that implies. None of the three current residents 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. 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 includes overnight stays, joining in with activities and a trial stay of three months, which can be extended. And an extra document was drawn up for the latest admission by the manager, listing all the facilities of the home and activities he could expect to engage in on and off site, as well as local community resources at Herne Bay and Canterbury. The document was adapted with photographs and symbols to make it as accessible as possible, so that the resident knew what to expect. This is judged exemplary practice. 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, which has been amended to identify the allocated bedroom, as required. Work has also been done to produce a much simplified picture / symbol assisted version of the contract for the residents. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 6. The preadmission assessment and care planning processes cover a range of health and personal care needs, as well as some social care needs. 7. The current residents were observed being supported in the daily routines, and observed interactions between staff and the residents were appropriately familiar and respectful during this inspection. 8. The current residents have a number of opportunities to influence their daily routines, and their responses are used to gauge their level of personal choice. 9. There are risk assessments to cover the residents as individuals, their activities and their environment (inside and outside the home), to maximise their capacity to be independent. 10. The arrangements for the storage and disclosure of confidential information is generally satisfactory. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 11 EVIDENCE: The format of the care plans is a comprehensive person-centred one, clearly designed to address the health and social care needs of the residents. The care planning processes include specialist input (e.g. from the Positive Behaviour Support Team and Community Learning Disabilities Team. The inspector has seen diagrams used to help one resident with special communication needs indicate what makes him happy and what he enjoys doing. One very promising development since the last inspection has been the introduction of “Opportunities” sessions, for one resident with special communication needs. This involves his being presented with a modest selection of choices (e.g. cereals, cheeses, colours) and being discreetly observed by staff to see if he shows any positive preferences. His capacity to make choices is reported to have already redefined his care package and changed assumptions being made about him. It is still early days, but the extension of this principle of working to other experiences and other residents (a start has been made with one) is judged potentially exemplary practice. Files are colour coded and systematically arranged to facilitate access. 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 care planning documentation. There was good evidence of risk assessments in respect of each resident, his activities and the environments he uses, on and off site. Key worker meetings are used to evaluate whether the care planning goals set are realistic, achievable and whether the residents 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 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. The service manager undertook to supply the Commission with a report on its findings, but this did not come in time for inclusion in this report. Avenues Trust has a policy on record keeping, their safe retention and disposal. The home keeps hard copy and electronic records. Cabinets, computers and office facilities are all properly secured. Each resident has a lockable facility to store money and valuables in. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 11. Residents have opportunities to learn and use practical life skills. 12, 14. Residents can continue to enjoy activities they were engaged in before their admission, as well as experiencing new activities on and off site. 13. The home provides residents with information (in an accessible format) about local community resources and supports them to use local public transport as well as the home’s own dedicated transport. 15. Families and friends are welcomed, and their involvement in the care planning processes is encouraged, subject to the residents’ wishes 16. The daily routines promote choice and independence, subject to risk assessments 17. Residents are offered a choice of suitable menus to suit their dietary needs and preferences, and are supported to plan and prepare or serve meals. Residents can choose where and when to eat. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 13 EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-today consultation thereon. The home maintains records of activities for each individual, which include scope for their feedback or refusal to participate. Residents were observed being supported to make decisions and choices during the inspection visit, and (as found at the last inspection) appeared to be thoroughly enjoying the range of activities offered to them. This is a home which makes sure residents have fun! One proudly told the inspector about the progress he’d made in his latest horse riding session that day. This home also offers support to residents 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 resident, for example, is currently being encouraged to do calculations, and will be managing more of his finances. He is already fastidious about keeping receipts and counts up money. 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, and there was anecdotal information on the extent to which staff support residents to maintain family links and friendships inside and outside the home. 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 phonecalls. 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 one resident’s dietary preferences. The dining area is a congenial setting but residents choose to eat at separate tables, with staff and can choose to 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 Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 14 seasons. The inspector joined the residents for lunch and judged the meal well prepared and presented. Records are kept of options actually chosen by individuals, as required. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 21 18. Residents have choice and control over most aspects of the personal and healthcare they receive, and the environment provides facilities for privacy. 19. The home ensures that the healthcare needs of residents are properly addressed. 21. Avenues Trust has a policy on care of the dying, to ensure residents are accorded with sensitivity and respect. EVIDENCE: The preadmission and care planning processes assess the extent to which each resident 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. One member of staff suggested that access to another bathroom might prevent some early morning tensions. Staff are available on a 24 hour basis to assist residents. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 16 The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician etc. Records have been set up on file to document access to a range of other healthcare professionals as appropriate All three residents have the same GP. Two were registered with this particular GP before their admission to this home, so benefited from some continuity of healthcare. The latest admission was not offered a choice, but the GP was chosen and retained for his specialist knowledge, so that the residents’ healthcare needs can be properly met. The medication arrangements were not assessed against the National Minimum Standards on this occasion. The home keeps a copy of the Royal Pharmaceutical Guidance and British National Formulary to underpin knowledge and practice. The home has a comprehensive policy on the ageing process and death, which has the resident’s personal and cultural preferences as its central principles. It gives guidance on planning for growing older; terminal illness and death (expected and sudden); as well as financial and other matters such as bereavement and counselling. It quite properly includes the retention of medication and reporting duties. Of particular interest was the appendix material detailing leading principles on a range of religious beliefs – Christian, Jews, Moslems, Hindus, Jehovah Witnesses, Bhuddists, and Mormons. This is judged an inclusive approach. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The manage and staff are attentive to the views and concerns of the residents, and a lot of work has been put into making the complaints policy more accessible to their special communication needs 23. There is a robust policy for responding to suspicions or evidence of abuse, and staff showed a commitment to challenge and report any instances, should they occur EVIDENCE: Avenues Trust has policies on complaints and whistle-bowing, which were judged comprehensive, and the inspector noted that the policy on complaints had been updated to take the Commission’s new title into account, as required by the last inspection. The complaints procedure also has a picture assisted version and CD version to make it more accessible to residents. There was only one complaint since the last inspection, which was judged effectively managed. As reported at the last inspection, the absence of recorded complaints is not judged a realistic reflection of day-to-day life, given the special needs and interactions of the residents. It is accepted that a lot of work has been done to draw up communication passports - the challenge continues to be to find ways of translating expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. There is currently no input from independent advocacy services, though the inspector understands the plan is to pursue Canterbury Advocacy Project which is setting up an outlet in Herne Bay. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 24, 25, 28. The standard of the property is good. The furniture is domestic in style, and comfortable. Residents have a choice of communal areas, and there are homely touches throughout. 26. Residents’ bedrooms are well maintained and personalised, and where they don’t have all the furniture or fittings prescribed by the National National Standards this is justified by documented risk assessments 27. Each bedroom has a wash hand basin, and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. 29. The home is not wheelchair accessible but has ample useable floor space throughout. The garden area is spacious and interesting. 30. The home is well maintained, clean and free of offensive odours. EVIDENCE: The location (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 Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 19 furniture tends to be domestic in style and there were homely touches throughout. The grounds are reasonably flat and damage by moles (several trip hazards) has been addressed since the last inspection. There are several discrete focal areas to draw the attention to, and to sit in, but there are no paths across it, for use when the ground is wet. The home has a “No Smoking” policy. Communal Areas 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 residents who use them. The kitchen is light, airy, clean and well maintained. No matters were raised for attention. Communal Bathrooms / WCs 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. No matters were raised for attention, although one member of staff suggested the provision on another bathroom facility might avoid some early morning tensions. Bedrooms All three bedrooms are single occupancy and one, which would otherwise have been slightly undersize, has been compensated with an adjoining room, which is used as a study / lounge by the occupant. All the bedrooms were inspected and found to be well maintained. In terms of their furniture and fittings, they were, however, generally not fully compliant with the provisions of the National Minimum Standards, but non-provision is in the process of being justified by fully documented consultation and risk assessment. Each bedroom was personalised, and each had its own TV and/or sound system. No matters were raised for attention. Yellow clinical sacks are being stored in a lidded wheelie bin in garden, then wheeled to the front for collection – this is an improvement on the arrangement found at the last inspection as it minimises the extent to which staff handle the contents. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 31. Avenues Trust Ltd has a range of systems in place to ensure the proper co-ordination of roles, policies, procedures and care planning to benefit the residents. 32, 35. Records and information from staff indicate a sound investment in training and development, and Avenues has exceeded the requisite level of NVQ accreditation of staff. 33. The numbers and skill mix of staff on duty is determined by the assessed needs of the residents 34. 36. Staff receive support and supervision to carry out their jobs. EVIDENCE: The following staffing arrangements apply to this home. There should be two care staff on the early shift, three care staff on the late shift, one member is care staff on sleeping night duty and 2-2 ½ flexi staff available every day. This was judged an appropriate level of staffing, in the light of information on the Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 21 assessed needs of the residents and staffing levels complied with this on the day of this inspection. Records confirm that each post-holder has a job description and person specification, and a process is in place to require staff to countersign policies as evidence of having read, understood and agreed to comply with their provisions, to ensure a consistent and co-ordinated approach, though this has yet to be completed. 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 Staff confirmed 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. 7/10 staff are reported to be accredited to NVQ Level 2 or above. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 37, 38. The registered manager is qualified, competent and experienced to run this home according to its stated aims and objectives. She has an accessible and facilitative management style, which has encouraged positive achievement among staff and residents. Avenues Trust is actively promoting Equal Opportunities in its policies, recruitment and the residents’ community presence. 39. Quality assurance and quality monitoring systems are in place to measure the home’s effectiveness. 40. Policies are comprehensive in their scope 41. Records required by regulation for the protection of residents and for the effective running of the home are properly maintained. 42. The registered manager ensures as far as is reasonably practicable the health, safety and welfare of residents and staff. Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 23 EVIDENCE: The registered manager has at least two years significant management and supervisory experience and achieved her Registered Managers’ Award and NVQ Level 3 accreditation in 2004. She is currently working towards her NVQ4 and is hoping to complete this by August 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 and her motivational skills were singled out as strengths. 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. 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 - though the latest one was not available at the time of this inspection. Over the last two inspections, twelve key policies have been selected for closer examination, and were judged comprehensive in their scope. Staff are required to sign checklists as evidence of their compliance with policies, which is judged diligent, although the process was by no means complete at the second viewing. Avenues Trust has a range of policies governing health and safety matters, which are underpinned by a robust level of investment in training and all maintenance records (with the exception of one gas safety check) were up to date and systematically stored. The home has the requisite insurance cover arrangements. 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 – 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.V277006.R01.S.doc Version 5.1 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 3 3 3 4 4 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 3 4 3 3 3 X Calcott Bungalow DS0000023345.V277006.R01.S.doc Version 5.1 Page 25 No 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. 4. Standard YA34 Regulation She 2 18(a) Requirement That all information detailed in Schedule 2 of the Regulations should be able to be accessed by the manager and be made available for Inspection. In order to comply with Reg 18(a) to ensure the health and welfare of the residents is protected it is necessary that the person in day to day control of the Home has access to these documents. Avenues Trust Avenues Trust will need to reach a formal, documented agreement with the CSCI over this matter Timescale for action 31/03/06 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.V277006.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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.V277006.R01.S.doc Version 5.1 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. 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