Inspection on 07/09/05 for Calcott Bungalow

This inspection was carried out on 7th September 2005.

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 4 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 06/01/06

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 Announced 06-07/09/05 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 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 Stationary 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 Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Calcott Bumgalow Address Calcott, Sturry, Canterbury, Kent, CT3 4NB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 3082900 01227 710196 calcott.bungalow@theavenuestrust.co.uk The Avenues Trust Limited Mrs Juliett Morrell Registered Care Home 3 Category(ies) of Care Home for Younger Adults (18-65) with a registration, with number Learning Disability of places Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/03/05 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 Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which was intended to introduce the new inspector to the staff and residents; to check compliance with matters raised from the last inspection (January 2005); and to reach a preliminary view on the day-to day running of the home. The inspection process took just under eleven and three quarter hours, spread over two days, and involved meetings with the manager, service manager, and four staff. The inspection also took into account feedback questionnaires from one resident and three relatives / visitors. The Inspector had the opportunity to meet all of the Service Users during the inspection, but was not able to engage in sustained discussion with them, due to their limited communication skills. The inspection also involved an examination of records and policies, and the selection of one resident’s case files (the most recent admission), to track his care. All three bedrooms, as well as the communal facilities, were inspected on this occasion, for compliance with the National Minimum Standards. Interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? What they could do better: Access to personnel records is an issue over which Avenues Trust will need to reach a formal, documented agreement with the CSCI. Decisions not to comply with the National Minimum Standards (e.g. over items of furniture in bedrooms) must be subject to properly documented / consulted risk assessments. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 6 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 Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 standard(s) 1, 3, 4, 5 1. The homes’ Statement of Purpose and Service User Guide are generally compliant with all the elements of this standard, though they could be further improved. 3, 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 is 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 EVIDENCE: Copies of the most recent Statement of Purpose and Service User Guide were supplied for inspection, and were judged generally compliant with the elements of the National Minimum Standard. These 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. Some recommendations were made to further streamline and improve them, most notably in respect of meeting the needs of prospective residents. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 9 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 step-by-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. Two residents had already spent many years together at Eastry Hospital, and their successful transfer to this home has been subject to the ongoing assessment of previous inspections. This inspector was shown an extra document 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 had been adapted with photographs and symbols to make it as accessible as possible, so that the resident knew what to expect. Feedback from his representative confirmed that his transfer had been managed effectively and that he had settled remarkably well. Each placement is confirmed with a contract, which is judged compliant with the elements of the National Minimum Standard, except that it does not identify the allocated bedroom, which is required. Work has been done to produce a much simplified picture / symbol assisted version of the contract for the residents. This is judged a good start but the document will require further simplifying and trying out with the residents. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 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. EVIDENCE: Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 11 The most recent admission was selected for closer examination on this occasion. A care plan was set up with risk assessments before the resident was admitted and was systematically built up thereon. 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 included, in the case in hand, specialist input (e.g. from the Positive Behaviour Support Team and Community Learning Disabilities Team); and the resident was given a choice of venue for his Person Centred Plan meeting, and chose a local pub-restaurant. A diagram was used to help him indicate what makes him happy and what he enjoys doing 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 the resident, his activities and environment on and off site. Key worker meetings are used to evaluate whether the care planning goals set are realistic, achievable and whether the resident is 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 will be concentrating on the effectiveness of the person centred planning processes and this include 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. Cabinets, computers and office facilities are all properly secured. Each resident has a lockable facility to store money and valuables in. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 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 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. EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-toCalcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 13 day consultation thereon. Residents were observed being supported to make decisions and choices during the inspection visit, and appeared to be thoroughly enjoying the range of activities offered to them. This home offers support to residents in maintaining their practical life skills, and this is underpinned by risk assessments and the specialist input as appropriate. Examples in the case file selected for inspection include the development of domestic skills (understanding the need for a balanced diet, cooking, making drinks, laundry, cleaning rooms, loading or unloading the dishwasher, collecting mail from the mailbox, and tending his fish tank); as well as personal or healthcare (oral hygiene, shaving, hygiene, capacity for self medicating). There are recreational activities both on and off site, and opportunities to access local resources such as shops, seafront, cafes and pubs, swimming, 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. The home maintains records of activities for each individual, which include scope for their feedback or refusal to participate. 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. 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 seasons. The inspector joined the residents for lunch and judged the meals well prepared and presented. Records are kept of options actually chosen by individuals, as required. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20, 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, 20. Residents are supported to take control of their medication 21. Avenues Trust has a comprehensive policy on the ageing process and death which commits the home to give personalised care. 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 guarantee their availability and privacy. Staff are available on a 24 hour basis to assist residents. 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 Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 15 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 partially assessed on this occasion, as the last two inspections found full compliance with the National Minimum Standards, and appeared appropriately managed. The home’s policy was judged generally comprehensive and 8/13 staff confirmed having read it – only two matters were raised to further improve it. When asked, the manager confirmed that the home keeps a copy of the Royal Pharmaceutical Guidance and British National Formulary to underpin knowledge and practice. The designated shift leader holds the key to the medication cupboard. Administration is generally done at the same time every morning, and each resident has a personalised approach. One resident has his medication decanted into a pot then onto a spoon because this is easier for him. A second resident has his medication decanted into a pot, and given to him in the pot. He then puts the medication onto his hand and takes it, with staff witnessing him doing so. The most recent admission has been assessed as capable of managing certain aspects of his medication. He could, for example, have medication in his room as long as he keeps it locked in cupboard, but in practice he prefers staff to keep it for him – he has a box for his medication and his own signing off chart, though the official medication administration record is marked by staff to show he is self administering. 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. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 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, although the policy on complaints requires updating to take the Commission’s new title into account. The complaints procedure also has a picture assisted version and CD version to make it more accessible to residents. 14 staff confirmed having read these policies and all four staff who met with the inspector showed a good understanding of the procedures and the need to challenge and report poor practice should it occur. However, there have been no complaints recorded in the last 12 months. Feedback from three relatives and one resident indicates a high level of satisfaction with the services received, and the rapport between staff and the current resident appeared appropriately familiar and respectful. However, 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. A lot of work has been done to draw up communication passports - the challenge now will 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. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 17 There is currently no input from independent advocacy services, though the plan is to pursue Canterbury Advocacy Project which is setting up an outlet in Herne Bay. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 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, but they don’t have all the furniture or fittings prescribed by the National National Standards 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, but trip hazards need to be managed. 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 Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 19 the home were inspected and found to be homely, comfortable and clean. The furniture tends to be domestic in style and there were homely touches throughout. The grounds are reasonably flat but damage by moles has created several trip hazards. 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. A few matters were raised for attention. 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. Non-provision must be justified by fully documented consultation and risk assessment. Each bedrooms was personalised, and each had its own TV and/or sound system. Yellow clinical sacks are being stored in a lidded bunker in garden, then transferred to front for collection – a locked wheelie bin would minimise the extent to which staff handle the contents. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 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. 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 EVIDENCE: Staffing rotas for the period 4-31 July 2005 were submitted for inspection, which showed the following staffing levels were maintained. There were invariably 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 assessed needs of the residents. Records confirm that each post-holder has a job description and person specification, and a process has been introduced to require staff to countersign policies as evidence of having read, understood and agreed to comply with Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 21 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 not inspected on this occasion, as a training matrix, previous inspections and information from staff confirmed a satisfactory level of investment. 7/10 staff are reported to be accredited to NVQ Level 2 or above. Less clear, however, was incontrovertible evidence of Avenue Trust’s recruitment process, as records have traditionally been kept at the head office. Access to personnel records is an issue over which Avenues Trust will need to reach a formal, documented agreement with the CSCI. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 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. 40. Policies and procedures are comprehensive in their scope. 41. Recordkeeping is clear and co-ordinated, and policies are comprehensive in their scope EVIDENCE: The registered manager has at least two years significant management and supervisory experience and has achieved almost all the requisite elements of NVQ accreditation. She has an impressive training record and has demonstrated a commitment to update her knowledge, skills and competencies. Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 23 The processes for managing the home are accessible, transparent and there are clear lines of accountability within Avenues Trust Ltd. Policies and procedures are comprehensive in their scope. The residents are all white British males. The staff group shows an appropriate gender split (five males, and six females, including manager. The manager said the home is generally able to give same gender care if required and Avenues has a “same gender” policy. The staff group is also predominantly white British but shows some diversity – one member of staff is Moroccan, another is African and a third (bank staff) is Zimbabwean, 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 Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 4 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 2 N/A 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Calcott Bumgalow Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 x x H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA5 YA26 Regulation 5 16 Requirement The Service User Contract needs to specify the allocated bedroom All three bedrooms need to be assessed against the elements of the NMS. Non-provision must be justified by a properly documented / consulted risk assessment. One bedroom only had one visible double socket. Bathroom / WC facilities. The following matters were raised for attention: · Toilet roll holders unstable in both communal WCs used by residents · Extractor in residents’ WC requires cleaning 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, Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 26 Timescale for action 30 11 05 30 11 05 3. YA27 23 30 11 05 4. YA34 Shedule 2 18(a) 30 11 05 documented agreement with the CSCI over this matter 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 YA1 Good Practice Recommendations Statement of Purpose and Service User Guide. The following matters are raised for attention: · Each document should be given an issue date, so that its currency can be evaluated · Each document would benefit by a contents page and numbered pages, to facilitate the reader’s access · It is strongly recommended that only published inspection reports are included, not drafts, so that Avenues Trust Ltd. will have had due opportunity of correcting or amending the draft · Each document needs to outline the relevant qualifications and experience of the registered provider and any registered Manager. · Each document needs to provide the organisational structure of the care home · Each document should outline the arrangements for visiting Consideration should be given to providing separate simplified / adapted versions of the Service User Guide to meet the individual needs of the residents It is recommended that Avenue Trusts policy on medication includes the need to routinely address the question of allergies; and includes specific detailes about the temperatures under which medication should be stored The master version of the complaints policy should be amended to give the Commissions new title Bathroom. A chair is recommended for comfort Storage of clinical waste. A locked wheelie bin is recommended to minimise the extent to which staff have to handle the contents 2. 3. YA1 YA20 4. 5. 6. YA22 YA27 YA30 Calcott Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 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 Bumgalow H56-H05 S23345 Calcott Bungalow V238211 060905 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!