Inspection on 24/07/08 for Denehurst

This inspection was carried out on 24th July 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Denehurst 7 Manor Road New Milton Hampshire BH25 5EW Lead Inspector Pat Trim Unannounced Inspection 24th July 2008 09:00 Denehurst DS0000071771.V367909.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 Denehurst DS0000071771.V367909.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. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denehurst Address 7 Manor Road New Milton Hampshire BH25 5EW 01425 612811 01425 628630 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) Contemplation Care Ltd Mrs Marie Anne McLoughlin Care Home 11 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - (LD) 2. Mental disorder, excluding learning disability or dementia (MD). The maximum number of service users to be accommodated is 11. Date of last inspection Brief Description of the Service: Denehurst is a large family home situated in a residential area, close to shops and local amenities. It was bought, with two other homes, from the previous providers in March 2008 by Contemplation Care Ltd. The home provides care for up to 11 people who have learning disability or mental disorder. Accommodation is provided on two floors in single rooms. Shared space includes a lounge/diner and a small conservatory. There is a large garden with seating area at the rear of the property. The fees are from £900.00 to £1560.00 a week. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use this service experience good quality outcomes. The information used to write this report was obtained in the following ways. We looked to see if we had received any complaints about the home and saw that we had not. We also looked at any information the home had given us about what might have happened since we visited. We used some of the information the provider gave us about the home in a form called the Annual Quality Assurance Assessment (AQAA). This is a form the home has to fill out every year to tell us what they are doing to make sure the home gives the people who have used the service the care that they want. We also used information we received from surveys. We sent surveys to four people who use the service to ask what they thought about it. We received four surveys back. We also sent four surveys to health care professionals and received two back. We sent four staff surveys to the home and asked them to give them to staff. We received four surveys back. A five and a half hour visit was made to the home by one inspector to carry out a key unannounced inspection. During the visit time was spent talking with three of the people who use the service to get their views about it. Some people in the home have limited verbal communication, so time was also spent observing staff practice and the interactions between people who use the service and staff. There was also an opportunity to get the views of two members of staff who worked in the home. Time was also spent discussing the provider’s plans for the home and looking at the environment. A random selection of documents was viewed. Three people who use the service were case tracked. This means their records were looked at to see how the provider identified their needs and made sure they were met. What the service does well: People who use the service have the opportunity to be involved in what happens in the home. They are given information in a variety of ways that makes sure they understand so they can complain about things if they are not happy. Comprehensive pre admission assessments make sure the home has detailed information about anyone wishing to move in. They are also encouraged to Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 6 make several visits to the home, including an overnight stay. This makes sure the registered manager is able to assess whether the home is the right place for the person and that they will get on with those already living there. People who use the service tell us they like living there and think they are able to make choices about how they spend their time. Comments included: ‘I can get up and go to bed when I want – I can choose what I do.’ And ‘I like going for walks on my own.’ People who use the service felt they had lots of opportunities to go out and to meet other people. What has improved since the last inspection? 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. Denehurst DS0000071771.V367909.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 Denehurst DS0000071771.V367909.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre admission assessments are completed that enable the registered manager to be sure people who use the service will only be offered a place if the home can meet their needs. EVIDENCE: The registered manager said the admission process had not changed since the new providers took over the home. The AQAA stated the admission process included the completion of an in depth assessment and visits to the home. The records showed only one person had moved to the home since the last inspection. This person had a detailed assessment of need completed prior to their admission and further information provided by their previous placement. The in house assessment included information about the person’s daily routines, personal care needs, health care needs and any potential risks. Feedback from four people who use the service showed they were involved in choosing to move to the home. The records showed the person who had recently moved into the home had been able to visit several times. People currently living in the home had been consulted about the person possibly moving into the home for a trial period. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred plans reflect the diverse needs of the people who use the service and ensure they consistently receive the support they need to live as they wish to. Risk assessment is used to identify and minimise any risks involved in activities people who use the service wish to take part in. EVIDENCE: The AQAA recorded the organisation used person centred planning that involved individuals in planning their care. People had an individual care plan, which identified their abilities and needs. This included a person centred plan that reflected the person’s views and wishes, in a format that was accessible to them, for example, in pictorial form. Plans clearly recorded where limitations had been imposed and the reason for them. For example, one person could not go out alone. The reason for this was because they became anxious and this sometimes led to aggressive behaviour. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 10 Information obtained during assessment was used to write the care plan. For example, the information about what was likely to cause anxiety in one person was used to write the action plan for staff to follow if this happened. This included physical intervention as a last resort and gave clear guidance as to when it should be used, what could be done and who could use it. Staff were able to describe the signs that indicated the person was becoming upset and had a good knowledge of the distraction techniques to be used. Feedback from four surveys completed by people who use the service showed they thought they were always able to make decisions about their lives. Three people living in the home also said they were able to choose how they spent their time. The responsible individual said that the current system of care planning was being reviewed as the organisation wanted to develop one that made it easier for people who use the service to be involved. A record was kept that showed care plans and risk assessments were reviewed on a monthly basis and amended as required. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The AQAA stated the home has ‘Flexible routines that respect individual residents choice where possible.’ It also recorded that personal profiles are completed with families so plans can be based on hobbies and interests. Community activities are encouraged and staff trained to support service users to maintain independence. Feedback from surveys completed by people who use the service and from those spoken to, evidenced they feel they are able to make choices about activities at all times. Comments included ‘I can get up and go to bed when I want – I can choose what I do.’ And ‘I like going for walks on my own.’ Staff Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 12 have organised a week’s holiday for everyone and those spoken with said how much they were looking forward to going. Information from the assessment is used to identify activities that the person using the service will enjoy. For example, one assessment identified someone liked football and a trip to a local football ground had been organised. Another person’s assessment recorded they liked helping with housework and staff were seen helping the person to do this. Person centred care plans recorded the individual daily routine for each person. For example, recording that one person liked to watch ‘Emmerdale’ and that another liked to be tucked into bed at night. The registered manager said people had the opportunity to go to outside activities. For example, some people went to a Skills for Life course at a local college, a keep fit class and swimming. People who use the service said they liked doing these activities and also enjoyed visiting the organisation’s other homes in the locality for parties and barbeques. One care manager stated that the home was particularly good at maintaining family relationships and made sure the ‘family always included in home events/social activities with my client. Always invited and always have a good time with their sibling.’ Care plans recorded family contact and next of kin. People who use the service said they liked the meals provided. Menus are planned on a three-week rota, but people may choose something different if they wish. A record was kept of individual choices that showed people had alternatives to the main meal. Individual care plans recorded any specialist requirements in respect of diet. For example, the assessment for one person identified they were at risk of choking on their food. A care plan had been put in place that required staff to make sure the person’s food was cut up before being given to them. Staff were aware this was a risk for this particular person and were seen following the care plan. Another person needed help with feeding. The care plan for this person gave clear instructions as to how this should be done and staff were seen following the plan. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Staff receive the training and guidance they need to enable them to manage medication safely. EVIDENCE: The care plans seen included guidance on how people liked to receive their personal care and recorded what they could do independently. For example, plans recorded whether someone could choose what they wore, when they liked to get up and go to bed and when they liked to have a bath or shower. Staff were observed following the guidance in individual care plans, supporting people to make choices about their personal care, and giving support sensitively and at the person’s own pace. Some people who use the service had limited verbal communication. The registered manager said she was working with a local day centre for one person to extend the use of objects of reference to enable the person to be more able to express their wishes and preferences. She was also working with Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 14 a communication specialist to develop a communication board for another person who uses the service. The health care needs of the people using the service are monitored and met. The pre admission assessment identified individual health care needs and arrangements were put in place to monitor them. For example, one person was seeing the specialist health care team before moving to the home. Their care was transferred to the local specialist health care team to continue providing support. The assessment for another person showed they had their eyesight regularly monitored. They had been transferred to a local optician. Daily records showed people were able to see a wide range of health care professionals such as doctors, specialist health care teams and opticians. The registered manager said staff accompanied people to appointments and records confirmed this. Feedback received from two health care professionals showed they felt the health care needs of people who used the service were monitored and met. They also felt people were treated at all times with dignity and respect. The AQAA recorded that the new organisation is going to introduce a tool that will enable staff to monitor nutritional needs. Individual records showed that people’s weight is monitored as part of their health care. The AQAA identified an objective to send all staff on refresher medication training. The registered manager confirmed that all staff were completing a 12 week long distance learning course at present. The medication procedure stated that staff are not permitted to give out medication until they have completed training and staff confirmed this was true. The majority of medication is supplied in a monitored dosage system and stored in a locked cupboard. The responsible individual said the organisation had ordered a new metal one that would comply with Royal Pharmaceutical guidelines. Medication is checked on receipt and a record of what has been received is kept. A record is also kept of any unused medication returned to the pharmacist. Staff were observed giving medication to people who used the service in accordance with the procedure. Individual records were signed as soon as medication had been given. One record was checked, which showed the record accurately reflected the amount given and unused. Records were kept of medication given ‘as required’ and care plans included clear guidance as to when this should be given. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to an effective complaints procedure. People are protected from abuse and have their rights protected. EVIDENCE: The home has a complaints procedure, which is available in a number of formats including pictorial. The responsible individual and registered manager said they were not satisfied the current pictorial format met peoples’ needs and were reviewing it. Feedback from four survey forms completed by people who use the service showed they feel confident they can make complaints and that they will be listened to. People spoken with confirmed they knew who to speak to if they were not happy about anything. The AQAA recorded the home had received no complaints and the commission had not received any either. The home had a policy and procedure about safeguarding, but did not have a copy of Hampshire’s most recent safeguarding procedure. The registered manager contacted Adult services to arrange to have one sent to the home. Staff spoken with knew about the whistle blowing procedure and their responsibility to report any allegations. The AQAA recorded that an identified objective was to make sure all staff have received up to date training on safeguarding adults. The registered manager confirmed staff received annual safeguarding training. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 16 Records showed the registered manager was aware of her responsibility to report any allegations of abuse. A recent alleged incident was referred to adult services who were satisfied the registered manager had taken appropriate action to protect the person using the service and staff. The registered manager said that only staff who have been trained are able to use restraint, following the guidelines in individual care plans. Plans seen included the statement that the person could only be restrained by staff who had received training. The training matrix showed that refresher training had been arranged for staff in August 2008 and 12 staff would be attending. Staff also had a manual for guidance about the use of restraint and training videos, which could be used for discussion and one to one supervision. The home has a system for looking after peoples’ money. A record is kept of any money received on behalf of the person using the service and any expenditure. Amounts are checked against the records by two staff at every handover. Receipts are kept but there is no system to identify which receipt relates to what expenditure. The responsible individual said the organisation has its own system for recording, which would be introduced at Denehurst. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home is comfortable but showing signs of wear and tear. The AQAA stated that the home employs someone to provide routine maintenance such as changing light bulbs. In addition the organisation employs a facilities manager who is going to draw up a 12-month improvement and refurbishment plan for the home. The responsible individual said the organisation plans to renovate the ground floor, carrying out much of the work whilst the people who use the service are on holiday. Plans include changing the ground floor bathroom into a wet room, which will improve the bathing facilities for people. New furniture is to be provided in the lounge. People spoken with said they liked the home and enjoyed furnishing their rooms, as they wanted them. They thought the home was kept clean. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 18 Cleaning is done by staff as part of their duties and people using the service help if they wish to. The registered manager said this had not always been recorded in individual care plans but she would make sure the information was added when each plan was reviewed. The AQAA stated that the home complied with fire and environmental health regulations. Hampshire Fire and Rescue service or the Environmental Health Office had carried out no inspections recently. It also recorded that the organisation plans to introduce regular audits of the environment and health and safety procedures. The AQAA recorded that six staff have completed infection control training and future plans include making sure all staff have received it. The home has a contract for the disposal of clinical waste. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. The home operates a robust staff recruitment procedure that protects people who live in the home. EVIDENCE: Feedback from 4 staff who completed survey forms showed they felt the employment procedure had been thorough and fair. The registered manager had a procedure for employing new staff which included all the required checks such as completing an application form, providing a full employment history, two references and having a Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check, before being offered a post. Two files for staff recently employed were viewed and evidenced the procedure had been followed and the required checks completed. Both staff had completed an induction during their first weeks of employment and feedback from 4 staff who completed surveys indicated 3 felt the induction offered covered what they needed to know well and 1 that it mostly did. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 20 The AQAA recorded that the organisation wishes to introduce induction based on Skills for Care guidance and also give staff the opportunity to complete the Learning Disability Awards Framework (LDAF). This will enable them to further develop the skills needed to support people with a learning disability. Feedback from 4 staff who completed surveys and 1 staff spoken with indicated they felt they were given training that was relevant and helped them understand individual needs. Comments received from 2 health care professionals showed they thought staff had the training and skills they needed to support people with a learning disability. The home employs 14 permanent staff and has 2 bank staff who provide holiday and sickness cover. Of these, 7 have completed a National Vocational Qualification and 5 are working towards it. Staff said they felt the new organisation provided an environment where they were encouraged to get qualifications. The AQAA stated that planned improvements included introducing an individual training and development plan through supervision and appraisal. The registered manager monitors individual training needs through supervision and a training matrix. She said she was currently reviewing training and, as stated previously, had arranged a number of relevant training courses, including restraint and challenging behaviour. The responsible individual said the organisation has a training co-ordinator who would be helping the registered manager. The AQAA recorded the home had a low staff turnover. This and the use of bank staff who know the home, provides people who use the service with continuity of care given by people they know. The registered manager said staffing levels are provided that enable people to go out and join in activities. The rota showed that each day shift has 4 staff on duty working a 12-hour day and there were 4 staff on duty at the time of the inspection visit. The registered manager’s hours are in addition to this. The night shift is covered by 1 waking staff, supported by 1 sleeping staff. People who use the service said they thought there was usually enough staff on duty to enable them to do the things they wanted to. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect and has effective quality assurance systems developed by the service providers. Systems are used that enable people who use the service to express their views on the care they receive. EVIDENCE: The registered manager has completed a National Vocational Qualification 4 in care and has the Registered Manager’s Award. She has been managing the home since March 2005, remaining in post when the current providers took over in March 2008. Feedback from staff surveys and comments made by staff show that they find her approachable and supportive. People who use the service said they liked the registered manager and were observed coming to the office to speak with her throughout the day. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 22 People who use the service had the opportunity to express their views at regular resident meetings. Minutes showed that they had been asked about what trips they wanted organised and involved in planning them. They had also been given information about the new organisation throughout the changeover period. They had been consulted about the possibility of a new person moving into the home and encouraged to say what they thought about them, following an overnight stay. The registered manager said annual surveys had also been used in the past to get feedback from residents and their families. The responsible individual said the organisation had their own quality assurance systems and would be using them for the new service. She was visiting the home to complete the monthly audit of the service under Regulation 26. The registered manager had copies of these reports. The organisation employs a facilities manager who will be responsible for monitoring the health and safety arrangements in the home. Information received in the AQAA, together with a random selection of documents seen at the home show that equipment is regularly serviced to ensure the safety of people who use the service and staff. Both people who use the service and staff join in regular fire drills to make sure they know what to do if the alarms go off. The registered manager uses the training matrix to monitor when staff need refresher training in mandatory courses such as food hygiene, first aid and infection control. Training certificates were seen on the files of two staff, which showed they had completed a number of these courses. The responsible individual said the training co-ordinator will be monitoring training needs and arranging appropriate courses to ensure all staff are able to access mandatory training. Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 23 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 “ ” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Denehurst DS0000071771.V367909.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone 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. 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