Inspection on 02/12/05 for Five Ways

This inspection was carried out on 2nd December 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Five Ways 19/06/09

Five Ways 20/06/07

Five Ways 12/06/06

Five Ways 15/07/05

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 Five Ways Kingsdown Park East Tankerton Whitstable Kent CT5 2DT Lead Inspector Jenny McGookin Announced Inspection 10:00 2 December 2005 nd Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Five Ways Address Kingsdown Park East Tankerton Whitstable Kent CT5 2DT 01227 277861 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) Adelaide Limited Mrs Paula Jane David Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th July 2005 Brief Description of the Service: Five Ways is registered to provide residential care for three adults with learning disabilities. The home caters for people of either sex, within the age range of 18-65 years. It is not wheelchair accessible and is not adapted for people with physical disabilities. The property is a spacious two-storey detached house in a quiet residential street in Tankerton. It has four spacious single bedrooms (one of which is for staff use), each with its own wash hand basin facilities. The home has a range of WC, bath and shower facilities, as well as a Jacuzzi (though this was not in use), which are conveniently located on the ground and first floors. The kitchen is on the ground floor along with the lounge, dining room, conservatory and a den (which is scheduled to be converted into a sensory room). The property has an enclosed garden to the rear, which has a patio area, and a swimming pool. The front of the property has been attractively landscaped. There is off road parking for two to three vehicles, and unrestricted kerb-side parking. There are bus routes at either end of the road. The home is within walking distance of shops and the sea front and is 5-10 minutes walk from Whitstable High Street, with all the transport and community resources that implies. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was this home’s second inspection since its registration, which was intended to review key standards from the last inspection; assess some standards not inspected on the last occasion and to reach a view on the day-to day running of the home. The inspection process took eight hours, and involved meetings with the proprietor / registered manager, the deputy manager, a senior support worker, two support workers and the activities co-ordinator. The inspection also involved an examination of records and documents and one resident’s case file. One resident kindly showed the inspector his bedroom and almost all the other areas of the home were inspected 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: The challenge will be to further develop one resident’s communication needs with objects or pictures of reference and further staff training in Makaton. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 6 Care plans should identify the practical steps and time lines to achieve objectives so that progress can be tracked. The quality of daily reporting will be crucial to the success of this. The work done on quality assurance is judged a very promising start. 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. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 contain a number of the elements of this standard, though they each require further attention to obtain full compliance and could be further improved in other respects. 2. There is a systematic preadmission assessment process, which identifies needs, preferences and interests 3, 4. Adelaide Care Ltd. has a careful admission process, designed to enable the prospective resident to sample the facilities, company and environment provided by the home, before their admission is confirmed. This process includes visits, overnight stays and a trial period. 5. Each resident’s placement is subject to a documented contract, This document is not, however, currently 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, each of which usefully details a range of elements of the services and facilities provided by this home. Each document needs to show an issue date so that the reader can judge its currency. Statement of Purpose. When assessed against the elements of the National Minimum Standard, the Statement of Purpose was, however, judged in need of Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 9 further attention to obtain full compliance. This effectively means that funding authorities, relatives and other representatives do not have all the information they could have to make informed placements and this must be addressed. The detail has been reported back to the home separately. Service User Guide. A number of elements listed by this standard were found to be missing and the detail has been reported back to the home separately. The preface to this document advises the reader that the text has been purposefully kept to a minimum because of the residents’ severe learning difficulties, and what follows on is a short sequence of statements about key elements of the home, illustrated in each case by a photograph, diagram or symbol. The approach is not consistently applied. If it is accepted that some of the residents would be better able to communicate verbally, and others would be better able to use Makaton and /or PECS symbols (Picture Exchange Communication System) etc., there needs to be a range of formats available to cater for this spectrum of need. Admission process. None of the three residents admitted to this home so far had any choice about their transfer from previous placements, as these decisions were led by the funding authorities in each case. However, Adelaide Care Ltd has an admissions process, based on multi disciplinary assessments and meetings, and which is inclusive of the resident’s responses (and their representatives) at key stages. This process includes visits, overnight stays, joining in with meals and a trial stay of one month, which the inspector understands can be extended. There was anecdotal information to indicate that the latest admission had been managed effectively and that he had settled remarkably well. One previous admission was, however, unsuccessful and extremely disruptive, culminating in a sequence of police interventions and a decision to terminate the placement. This would underpin the need for a measured, pre-emptive approach to the pre-admissions process, before confirming placements. Contract. Each placement is confirmed with a contract, which is judged generally compliant with a number of the elements of the National Minimum Standard. But it does not identify the allocated bedroom, which is required. It also needs to identify any specialist services/therapeutic intervention, and any policies or rules, which may limit personal freedom; it should detail how fees are calculated. The contract should be available in a format/language appropriate to each service user’s needs, and/or reasonable efforts need to have been made to explain the contract to each service user Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 wide range of health and personal care needs, as well as some social care needs. 7. The current residents were observed being supported to make choices of decisions, and observed interactions between staff and the resident were respectful during this inspection. The home needs, however, to take more control over the care plan reviews – matter raised at the last inspection. 8. The current residents have a number of opportunities to influence their daily routines and the running of the home, and their level of involvement is a matter 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. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 11 EVIDENCE: In a number of key respects the findings from the last inspection were confirmed by this inspection. The most recent admission was selected for closer examination on this occasion. There was a range of preadmission assessments on file, which were in the first instance drawn up by the funding authority (in this case a London borough), then updated by the home’s own. The format of the care plan, which follows on, is designed to address the health and social care needs of the resident, particularly when underpinned by documents such as a “Likes and Dislikes” document. It is written in the 1st person to keep the resident’s perspective central to the process. But it was not yet available in an accessible format to meet the special communication needs of the resident in question. Adelaide Care Ltd has its own Community Outreach Worker and Education Development Worker to promote identified needs. Risk assessments are properly linked to the care planning process (daily living routines, behaviour management, safety in the community, finances). The resident in question was observed being supported by staff to modify his behaviour. Another was observed being supported to make day-to-day decisions and choices. However, there was no evidence of policies being reproduced in accessible formats and there are currently no plans to involve the residents in the development of policies, staff recruitment or service development. The inspector was advised that care plans are being reviewed 4-6 weekly. But it was not clear how the home establishes any emerging unmet needs so that pre-emptive action can be taken. One discontinued placement was subject to a sequence of violent outbursts and police interventions, before being resolved by the termination of the placement. The home still does not, moreover, appear to be leading on reviews of care plan objectives, and still appears to be overly reliant on the Care Managers to provide documentary evidence of formal review processes. The home needs to take more control over this process. The home’s arrangements for keeping confidential information secure against unauthorized access was satisfactory. Since the last inspection, a dedicated office had been established on the first floor and all cabinets and office facilities are all properly secured. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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, 16. Staff enable residents to maintain and develop social, emotional, communication and independent living skills. The daily routines promote choice and independence. 12. Staff support residents to undertake training and to take part in fulfilling activities. 13, 14. This home has a dedicated Leisure Activities Co-ordinator and offers a range of activities inside and outside the home. Links with the community are good, and support and enrich the residents’ social and educational opportunities. Activities are recorded. 15. There are open visiting arrangements, and the home is well placed for access to local community resources. Staff support residents to maintain links with families. 17. The meals in this home offer choice and variety and are catering for this resident’s needs and preferences. Meals are enjoyed, unhurried and the setting is congenial. 18. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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. This home has continued to offer support to its first resident, who the inspector met briefly at the last inspection, to maintain and develop his practical life skills. He has been attending Canterbury College for a carpentry course and is also able to pursue this interest at one club. He attends clubs for arts and crafts sessions, computer courses (including use of the Internet) and social events. And he regularly goes out in the community to a gym, museums cafes etc i.e. local mainstream community activities not confined to or identifiable with disabilities. He is said to be able to manage pocket money, with support. Once a week staff support him with cooking sessions and he had recently been making a Christmas card. The home maintains records of activities and he has a scrap book to illustrate his activities – though the home was still waiting for some photographs to be developed at the time of this inspection visit. An intensive programme of work was being set up for a second, more recent resident, using the specialist services of an independent organisation (affiliated to SCOPE), which identifies the ways individuals with special communication needs express themselves and supports staff to recognise and promote selfexpression, through one-to-one training and follow-up visits. The trainers also spoke to this resident’s advocate as part of this process. This has been usefully underpinned by Makaton training for the residents’ activities coordinator plus training in managing his diabetes. There was anecdotal information about the extent to which he is able to participate in ball games, his introduction to a trampoline and his progress with making eye contact. There are open visiting arrangements, which have been confirmed by feedback from one relative. One resident is supported to manage a weekly phone card. Staff dial the number for him to use the phone. There are two cordless handsets, which can be taken into bedrooms for privacy as well as the office phone. Dietary needs and preferences are established as part of the preadmission assessment process, and confirmed by the care plan and day-to-day consultation. Each resident has a menu book which is used to record what is eaten for each meal, as required. There was anecdotal information to confirm that the residents’ individual needs and preferences were being catered for. The dining area is a light spacious area, which provides a congenial setting for meals but the residents can choose to eat elsewhere. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 the following standard(s): 18, 10, 20, 21 18, 19, 20. The residents receive an appropriate level of support with their personal, emotional and healthcare needs. Personal care is offered in a way protect their privacy and dignity and promote their independence. 19, 20. The health needs of the residents are well met with evidence of access to a range of healthcare services. 21. The home has a policy on the management of the death of any service user, as required, though two matters are raised for inclusion EVIDENCE: The preadmission and care planning processes assess the extent to which each resident can manage their own personal care, and their choice and control is actively promoted by staff. All the bedrooms are single occupancy and bedroom doors have double-acting locks to guarantee their availability and privacy, while enabling staff to access the rooms in an emergency. There are enough toilet and personal care facilities (baths, showers, wash hand basins) – although these were undergoing substantial refurbishment at the Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 15 time of this inspection visit and not all readily available. 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. The home also accesses care managers, psychiatrists and psychologists as appropriate. At the last inspection, the home was working with its own medication administration arrangement and record system, but has since obtained a copy of the Royal Pharmaceutical Society Guidance to ensure its practice is compliant with best practice, underpinned by training (including specialist training e.g. insulin management). The home keeps its medication and records in a lockable facility, but these were not stored in an orderly fashion – a proper medication cabinet needs to be introduced so that storage and access is more systemmatic. The home has a policy on the management of the death of any service user, as required, but this policy needs to include the duty to retain records after any death for three years after the date of the last entry, and medication for seven days in case there is a coroner’s enquiry. One reference to the Commission’s old title needs to be updated. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 the following standard(s): 22, 23 22. The home has a complaints procedure, which descries the process and timeframes involved, but one matter is raised for inclusion and this is not in a format to meet the special needs of the residents. 23. Residents are safeguarded against abuse. EVIDENCE: The home has a complaints file, which usefully details its guiding principles in its preface, and describes the arrangements, procedures and timeframes for each stage. However, it gives the Commission as an option if the complaint is unresolved. This is an incorrect interpretation of the National Minimum Standard (22.3) and needs to be amended to offer this as an option at any stage, if that is the complainant’s preference. There was only one complaint on file, from one resident about the disturbance caused by another (who has since left the home). Given the sequence of episodes involving the former resident as subsequently reported to the Commission, this is not judged a realistic reflection of the atmosphere of disquiet he created. The most recent resident has special communication needs, which will need to be catered for. The challenge for this home will be to interpret expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can properly judge compliance with this standard. Staff induction covers a range of relevant adult protection policies: challenging behaviour; incident and accident recording; complaints; whistle-blowing; abuse and adult protection. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 17 In discussions with staff, they invariably confirmed their commitment to challenge and report any instances of abuse, should it occur. The rapport between staff and the current resident appeared appropriately familiar and respectful. Feedback from one resident confirmed that he felt he was in safe hands, and that he would raise any issues with staff. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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, 27, 28, 30 24, 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. Further investment is planned to make the home environment more safe and to install a sensory area, to enhance the resident’s lifestyle. 27. Each bedroom has a wash basin cubicles, and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. 29. The home is not wheelchair accessible and although it has ample useable floor space throughout, it is not adapted for people with physical disabilities. 30. The home is well maintained, clean and free of offensive odours. Consideration must be given to providing an alternative route for access to the ground floor WC/bathroom. EVIDENCE: The layout of this home is generally suitable for its registered purpose. All areas of 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 rear garden, although monopolised by the swimming Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 19 pool and patio, provide pleasant discrete focal points and congenial areas to walk or sit in. The home has a “No Smoking” policy. Communal Areas These are all on the ground floor. There is a spacious formal lounge at the front of the home, with a split level “den” (which is scheduled to be converted into a sensory area) forming a discrete room at its far end. The dining room is at the centre of the home and is linked on one side to the kitchen and at its far end to the conservatory and rear garden. All the chairs (dining, lounge and conservatory) belong to suites and are therefore uniform in style – a range of chairs (e.g. some with arms, or set at different heights) would give residents more choice. Because of identified trip / accident hazards, much of the stonework and sharp edging (in the den area in particular, where there is a split level well) have been covered and are scheduled for removal. The kitchen is light, airy, clean and well maintained. Communal Bathrooms / WCs There are WC facilities on both floors, and a choice of bath, shower and Jacuzzi facilities - all of which are reasonably accessible to bedrooms and communal areas; although some were undergoing substantial refurbishment and not readily available at the time of this inspection. Bedrooms All the bedrooms are spacious and single occupancy. All the bedrooms were inspected and found to be well maintained. In terms of their furniture and fittings, they were generally compliant with the provisions of the National Minimum Standards, but some elements were identified for inclusion at the last inspection and were still awaiting delivery. Every bedroom also has a TV point. No matters were raised for attention on this occasion. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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): 32, 33, 34, 35, 36 32. The registered person has ensured that staff have the competencies to meet the residents’ needs, and has made a commitment to ensure that the remaining 40 of the team have undertaken or obtained NVQ accreditation. 33. The home has an effective staff team, with sufficient numbers and complementary skills to support residents’ assessed needs. 34. The registered person operates a thorough recruitment procedure. 35. The registered person ensures there is a staff training and development programme. 36. Staff receive the support and supervision they need to carry out their job. EVIDENCE: Staffing rotas for the four-week period 7 November to 4 December 2005 show that the waking / working day has been interpreted as 7am till 10pm, and that one could reliably expect to find between 2-4 staff on duty. The deputy was on site for 3/7 days each week and the senior support worker covered another 3/7 days each week. Less clear, however, was the arrangements for line managing the intervening day each week. At night there were invariably two sleeping staff on site on call. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 21 There are no dedicated ancillary staff (e.g. cooks or cleaners). These tasks are covered by the staff responsible for direct care, and one of the current residents is supported to carry out some domestic chores. Once or twice a week there is also a Leisure Activities Co-ordinator. The manager is required to detail her own on-site hours on staffing rotas; and to also record ancillary hours (cooking and cleaning) separately, where staff duties are split between direct care tasks and ancillary work so that anyone authorised to inspect the records can readily evaluate the staffing arrangements. All personnel files were in good order and provided good evidence of a systematic approach to recruitment, induction and training. There is an induction programme to cover a range of issues: the organisational arrangements; health and safety; residents’ issues (special needs, medication, personal care, challenging behaviour and care plans / programmes); administrative tasks and work practices. This period is also used to identify further training needs. Each personnel file included a training record (which includes TOPSS training), and copies of resultant certificates. Staff have confirmed having had a range of training opportunities, such as food safety, fire safety, manual handling, First Aid, and challenging behaviour. See also section on “Lifestyle” for details on specialist input to meet one residents’ special needs. All the staff who met with the inspector confirmed that they had formal supervision from their line manager, though the frequency of this varied – usually every 1-2 months, thereby exceeding the National Minimum Standards. The line management was said to be accessible and supportive. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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. The registered manager has a range of relevant qualifications and experience to run the home. 38. The management approach is open, positive and inclusive. 39. Effective quality assurance and quality monitoring systems are in place to measure the home’s effectiveness. 40. The home’s written policies and procedures comply with accredited standards 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. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 23 EVIDENCE: The registered manager has a range of relevant qualifications (City & Guilds, BTEC Diploma, Higher National Diploma, Tavistock Urban Community Studies, Diploma in Social Worker (CETSW), BA Hons International Social Work) plus 17 years experience working with adults, children and their families. This is a home, which has been able to demonstrate good progress with its inclusive approach to its first resident. He is clearly benefiting from access to a range of fulfilling activities such as computer work, carpentry, arts and crafts sessions as well as to mainstream community resources not immediately identifiable with or confined to his special needs. The rapport between him and staff was judged appropriately relaxed and respectful. Suitable investments are being made to meet the needs of the second resident, but he was still in the process of settling at the time of this inspection, so it was judged too soon to evaluate the effectiveness of the placement. The home has a policy and procedure for Quality Assurance, which is usefully prefaced by statements about its guiding principles and includes questionnaires for use with residents (though there is as yet no picture or symbol assisted version), referring agencies, care managers and relatives. Feedback comments to date were judged encouraging. Only one concern was raised – in respect of one resident’s weight gain. The registered manager has ensured that key policies and procedures are in line with accredited models – examples include, the home’s own code of conduct (which has been checked against the General Social Care Council model) and its own medication policy (which has been checked against the Royal Pharmaceutical Council model) and its own policy on adult protection (which has been checked against the Department of Health “No Secrets” document and the local Kent and Medway protocols). This is judged a robust approach. Property maintenance records were judged generally in good order and maintained in the best interests of the residents, though the inspector noted on this occasion that annual gas safety checks were slightly overdue. At the last inspection, fire safety maintenance checks were found to be up to date, and this was confirmed by this visit. At the last inspection weekly petty cash accounts and financial records were judged fully accountable and properly supported by receipts. The home has the required public liability insurance cover. Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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 2 3 2 3 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 4 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Five Ways Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 X DS0000047387.V254537.R01.S.doc Version 5.0 Page 25 Yes 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 Standard YA1 Regulation 4& Schedule 1 5 Requirement The registered person must ensure the Statement of Purpose is fully compliant with the National Minimum Standard and regulations. The registered person must ensure the Service User Guide is fully compliant with the National Minimum Standard and regulations. The registered person must ensure the Contract is fully compliant with the National Minimum Standard and regulations. The home needs to make more appropriate provision for the storage of medication and medication administration records The complaints procedure needs to be amended to offer this as an option at any stage, if that is the complainant’s preference. Staffing Rotas. The following matters are raised for attention: - The manager is required to detail her own on-site hours; - The rotas must record ancillary hours (cooking and cleaning) DS0000047387.V254537.R01.S.doc Timescale for action 31/03/06 2 YA1 31/03/06 3 YA5 5(b)(c) 31/03/06 4 YA20 22 31/03/06 5 YA22 22 31/03/06 6 YA33 Schedule 4(7) 30/11/05 Five Ways Version 5.0 Page 26 separately, where staff duties are split between direct care tasks and ancillary work so that anyone authorised to inspect the records can readily evaluate the staffing arrangements. 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 2 3 4 Refer to Standard YA1 YA5 YA7 YA21 Good Practice Recommendations The registered person must ensure the Service User Guide is available in a range of formats to meet the individual residents’ special communication needs. The registered person must ensure the Contract is available in a range of formats to meet the individual residents’ special communication needs. The home needs to take more control over the formal care plan reviews. The policy on the management of the death of any service user needs to include: - the duty to retain records after any death for three years after the date of the last entry, and - medication for seven days in case there is a coroner’s enquiry. One reference to the Commission’s old title needs to be updated. Complaints. The challenge for this home will be to interpret expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can judge compliance with this standard. 5 YA22 Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 Page 27 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 Five Ways DS0000047387.V254537.R01.S.doc Version 5.0 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!