Inspection on 20/06/07 for Five Ways

This inspection was carried out on 20th June 2007.

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

The inspector found 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 3 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 12/06/06

Five Ways 02/12/05

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 Key Unannounced Inspection 20th June 2007 10:00 Five Ways DS0000047387.V338830.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 Five Ways DS0000047387.V338830.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. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 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.V338830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th June 2006 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. The property is a spacious two-storey detached house in a quiet residential street in Tankerton. It is not wheelchair accessible and is not adapted for people with physical disabilities. It has four spacious single bedrooms (one of which is for staff use), each with its own wash hand basin facilities. There are three communal WCs, two baths (one of which is also a Jacuzzi, though it is not currently in use), one shower and one shower attachment - all of 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 has been converted into a sensory room). The property has an enclosed garden to the rear, which has a patio area, and a swimming pool, though this has more recently been emptied and covered with decking. 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. The current fees for the service at the time of the visit were £2,253.00 per week. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is Adelaidecare@hotmail.co.uk Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection site visit, which was intended to review findings on the last inspection (June 2006) in respect of the day-to day running of the home; and to check compliance with matters raised for attention on that occasion. The inspection process took just under seven hours, and involved meeting with the proprietor (who is also the registered manager); the shift leader and a support worker. None of the service users was able or (in one case) inclined to interact meaningfully and remained so throughout the day, though one did choose to sit in the office while documents were being assessed there. The inspection involved a review of the premises and a range of records. One service user’s files were selected for care tracking (as the other two had been case tracked on previous visits). What the service does well: The location of this home is generally suitable for its stated purpose, convenient for visitors and offers ready access to community and seaside resources. Property maintenance checks were in good order, and the home has been tidy, clean and odour free whenever inspected. This home is judged an excellent quality service overall, with substantial strengths. Where weaknesses emerge the service recognises them and manages them well. It shows all the positive features of a good service plus a sustained track record. Leadership and management are effective. There is a proactive and innovative commitment to service development and improvement. There are appropriate quality and risk management strategies in place. The home prioritises the use of its resources. There is a rights-based approach to service delivery. Service users needs are thoroughly assessed, monitored and reviewed. There are consistently positive outcomes for people using the services and key standards are met. The home is working in partnership with people using the service, their families, regulators and other agencies. It is viewed positively by stakeholders. It takes a positive and proactive approach to comments and suggestions. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 6 The staff team is competent, committed, well-trained and well deployed. This is a staff team, which feels well invested in, and supported on a day-to-day basis. This home has an open and inclusive culture that values, promotes and celebrates equality and diversity. The rapport between the manager, staff team and service users is appropriately familiar, relaxed and respectful. An assured level of compliance was found with almost all aspects of the National Minimum Standards inspected. Record keeping is systematic and the person-centred care plans are judged very holistic. 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. Five Ways DS0000047387.V338830.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 Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. 1, 2, 3, 4, 5 Prospective service users and their representatives do not have all the information needed to decide whether this home will meet their needs. Prospective service users do, however, have their needs properly assessed as part of the admission process. There is a contract, which sets the terms and conditions that apply to the service, though it will require further attention. EVIDENCE: The home’s Statement of Purpose, Service User Guide and contract have each been further revised since the last inspection, and copies were supplied for inspection. Each document usefully details a range of elements of the services and facilities provided by this home. When assessed against the elements of the National Minimum Standard, however, each document was still judged in need of 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 Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 9 informed placements and this must be addressed. The detail has been reported back to the home separately. The word-by-word transcription of text into symbols diagrams and photographs. Despite some streamlining, this creates very intense documents, made more problematical in some instances by a number of duplications and contradictions. And the approach is not consistently applied, sometimes addressing the service user directly, but in other cases aimed at a more informed articulate reader. It was difficult to see what people with severe learning disabilities could make of some concepts or terminology used. Findings from the last inspection still stand. Specifically, if it is accepted that some of the service users 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 separate formats available to cater for this spectrum of need. Some statements of provision simply do not reflect current practice, and are likely to mislead and disappoint the representatives of prospective service users e.g. involvement of service users in the development of policies or in staff recruitment. The distinction between service aspirations and current practice needs, therefore, to be more clearly defined. None of the three service user 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 service user’s responses (and their representatives) at key stages. This process includes visits, and can include overnight stays, joining in with meals and a trial stay of one month, which can be extended. In the case of the latest admission, the home’s system of daily reports was set up before his admission and his stay is being reviewed and extended in three monthly intervals. Records indicated that the current service users’ admissions had been managed effectively and that all three service users had settled down together remarkably well. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6, 7, 8, 9, 10 Individuals are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: In a number of key respects the findings from the last three inspections were confirmed by this inspection. Since the last inspection, the home has introduced “Listen to Me” documents, which are designed to address the health and social care needs of each service user, and which are intended to inform care practice. They are in each case written in the 1st person to keep the service user’s perspective central to the process. And one is currently being trialled in a symbol-assisted format to see if it can better meet the special communication needs of the service users. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 11 Risk assessments are properly linked to this care planning process (daily living routines, behaviour management, safety in the community, finances etc). There was good evidence of daily reports being summarised 4-6 weekly, with a view to informing the care planning process. But the home is still overly reliant on the Care Managers to lead formal reviews of care plans. The home’s arrangements for keeping confidential information secure against unauthorized access was judged generally satisfactory. Cabinets are lockable and computerised records are password protected. Since the last inspection, a dedicated office had been established on the ground floor, overlooking the entrance. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 11, 12, 13, 14, 15, 16, 17 Service users are supported to make choices about their life style and to develop their life skills. Social, educational, cultural and recreational activities meet individual’s assessed needs and expectations. EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-to-day consultation or interpretation (where two service users do not have verbal skills) thereon. Adelaide Care Ltd has access to its own Community Outreach Worker, and an Activities/Education co-ordinator as well as a music therapist, to promote Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 13 identified needs. However, the music therapist is the only one to produce documented accounts of her input, the other developmental workers are tasked to contribute to community programmes and monthly summaries, so that the care planning processes are clearly inclusive. Since the last inspection, the home has introduced a minibus, to good effect. One service user has been continuing to attend Canterbury College for a carpentry course. He also attends clubs for arts and crafts sessions, computer courses (e.g. at the Umbrella Club in Whitstable, and this includes the supervised use of the Internet) and a range of social events. He used to attend a gym in the community to a gym, but has more recently lost the motivation to persevere with this, even though some gym equipment was purposefully bought in for him to use at the home. He continues to visit museums, cafes and trips to London etc i.e. local mainstream community activities not confined to or identifiable with disabilities. He is able to manage pocket money, with support. Staff also support him with shopping trips and cooking sessions. And he goes home every other weekend. All the staff have had some Makaton training, to help them communicate with another service user, as well as behaviour management training - but it was not possible to see this in action on this occasion because he was not inclined to interact while I was present. There was, however, good feedback in a report from his advocate about the way he had been settling and how he was not resorting to the level of self injurious behaviour as before, or stealing food from the kitchen. He was said to enjoy walks in the community, and short sessions in the home’s sensory room. The third service user (the latest admission) enjoys a range of activities: swimming, walks, drives to local shops, and more sedentary activities such as aromatherapy, arts and crafts, puzzles, music therapy and the home’s own sensory room. In each case the home maintains records of the service users’ activities and there are scrap books of photographs to illustrate them. There are open visiting arrangements. One service user is supported to manage a weekly phone card, and has learned to dial some numbers for himself. 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 service user has a menu book / diary, which is used to record what is eaten for each meal, as required. And this indicates a personalised diet. One service user’s weight gain (which was raised for attention by feedback from his family) is being monitored and managed. Although still clearly overweight, weight charts indicate a steady weight loss. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 14 The home’s commitment to promoting diversity is not only evident in the ethnic mix of staff and service users, but also in their celebration of cultural events such as Easter, Chinese New year, Caribbean festivals and Diwali. This is said to include traditional meals, and present giving. The dining area is a light spacious area, which provides a congenial setting for meals but the service users can choose to eat elsewhere. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 18, 19, 20 The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The preadmission and care planning processes assess the extent to which each service user can manage their own personal care, and their choice and control is actively promoted by staff. Daily records are maintained. 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. Observed practice was judged appropriately familiar and respectful, and occasional outbursts were managed effectively. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 16 There are enough toilet and personal care facilities (baths, showers, wash hand basins) – and these have been completely refurbished to a high standard, although the Jacuzzi facility continues to be unavailable to the service users. Staff are available on a 24 hour basis to assist service users. There was good anecdotal information about how one service user’s incontinence had been successfully managed. The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician. The home also accesses care managers, district nurses and specialists (e.g. in behaviour management interventions) as appropriate. The home uses the monitored dosage system (MDS) from Boots The Chemist, which also provides training and its own medication administration record (MAR) sheets. Recording standards were judged satisfactory, although the question of allergies needs to be more routinely recorded in each case (matter raised at the last inspection and found to be still outstanding). The home has 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, with District Nurses providing back up). The home keeps its medication in lockable wall-mounted facilities and there is also a dedicated fridge and a contract in place for the storage and collection of SHARPS. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are supported to express their concerns, and there is a complaints procedure in place. Service users are protected from abuse, and have their rights protected. EVIDENCE: The home has a complaints procedure, which usefully details its guiding principles in its preface, and describes the arrangements, procedures and timeframes for each stage. A copy is included in the home’s Statement of Purpose, Service User Guide, and the “Listen to Me” document identifies who service users can speak to about things they aren’t happy about. A pictorial guide has also been given to each service user. However, the absence of registered complaints is not judged a realistic reflection of communal living, particularly where outbursts are commonplace. The challenge for this home will, therefore, continue to be to interpret expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the records can properly judge compliance with this standard. It is accepted that a lot has been done to improve the information available. Staff have been given training on interpreting behaviours, with more in prospect. There was evidence of advocacy being used to prepare and settle one service user in, and the home’s public information commits the home to involve the service users in as much of the political process as they are able. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 18 Staff induction covers a wide range of relevant adult protection policies: challenging behaviour; incident and accident recording; complaints; whistleblowing; abuse and adult protection. This list is not exhaustive. In discussions with staff, they have invariably confirmed their commitment to challenge and report any instances of abuse, should it occur. The rapport between staff and the current service user appeared appropriately familiar and respectful. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. This home provides service users with a safe, well-maintained and comfortable environment. The physical design and layout of the home encourages freedom of movement and independence. 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 and comfortable. And the level of cleanliness is judged exemplary. The furniture tends to be domestic in style and there were homely touches throughout. The rear garden is no longer monopolised by the swimming pool. This has been emptied and covered with decking to provide (along with the patio) pleasant discrete focal points and congenial areas to walk or sit in. The prospect of a raised sensory Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 20 garden in one corner should make this facility even more attractive. The home has a “No Smoking” policy. The communal areas are all on the ground floor. There is a spacious formal lounge at the front of the home, which has restricted access, for formal meetings and accompanied service users. At its far end is a split level “den” (which has been converted into a sensory area) forming a discrete room. And there is a second lounge linked to the dining area, for everyday use. The dining room is at the centre of the home and is linked on one side to the kitchen and at another side to the second lounge, conservatory and rear garden. All the chairs (dining, lounge and conservatory) belong to suites and are therefore uniform in style – this has not caused any discomfort. Because of identified trip / accident hazards, in the den area in particular, where there is a split level well, all edges have been covered and padded. The kitchen is light, airy, clean and well maintained. There are WC facilities on both floors, and a choice of bath and shower facilities - all of which are reasonably accessible to bedrooms and communal areas; and these had all undergone substantial refurbishment since the last inspection. There is also a Jacuzzi, but service users do not have access to this. 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, and every bedroom also has a TV point. As was the case at the last inspection, no matters were raised for attention. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent 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, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The waking / working day has been interpreted as 7am till 10pm, and visitors should expect to find between 2-3 staff on duty. This arrangement was in fact confirmed by this unannounced site visit, and by the staffing rotas supplied. There are two shifts (each with an identified shift leader) to cover the week (Mondays to Thursdays, then the next shift covers Thursdays to Mondays) and this involves staying overnight in each case. This arrangement is said to work well. There is extra input from a Community Outreach Worker, and an Activities/Education co-ordinator as well as a music therapist. And the home has ready access to a pool of bank workers. At night there are invariably two sleeping staff on site, on call. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 22 The manager is in regular attendance (three days each week, from 12-7pm plus spot checks, including weekends). There are no dedicated ancillary staff (e.g. cooks or cleaners). These tasks are covered by the staff responsible for direct care, and “shift planners” are used to record cooking and cleaning duties separately, so that anyone authorised to inspect the records can readily evaluate their scope for direct care. Two of the current service users are supported to carry out some domestic chores. Three personnel files were selected at random for assessment for compliance against the National Minimum Standards, and were found to be in exemplary order. This company can provide good evidence of recruitment, induction and training (which includes TOPSS training). At each inspection visit, staff have confirmed having had a range of training opportunities, such as food safety, fire safety, manual handling, First Aid, and challenging behaviour – as well as specialist input to meet the service users’ special needs. Both staff who met with the inspector on this occasion confirmed feedback at previous inspections and records, that they had formal supervision from their line manager, which in some cases exceeds the National Minimum Standards, and appraisals. The line management was said to be accessible and supportive. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The manager is qualified and competent and the ethos of the home is based on openness and respect. There are comprehensive quality assurance and business planning systems in place. 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 18 years experience working with adults, children and their families. She has not had any further training since December 2005. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 24 This is a home, which has been able to demonstrate good progress with its inclusive approach to its service users. They have all been clearly benefiting from access to a range of fulfilling activities as well as to mainstream community resources not immediately identifiable with or confined to their special needs. 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 service users, referring agencies, care managers and relatives. Feedback comments continue to be encouraging. As reported at previous inspections, 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. Despite public information to the contrary (see section on “Choice of Home”, there are as yet no firm plans to involve the service users in the development of policies, staff recruitment or service development. Only one policy (complaints) has been reproduced in a more accessible format. Property maintenance records were judged in good order and maintained in the best interests of the service users. The home has the required public liability insurance cover. Weekly petty cash accounts and financial records are judged fully accountable and properly supported by receipts. The manager was able to supply a very detailed business plan for the current financial year, and equally detailed plan budgetary forecasts to support it. The plan makes conspicuous references to the same core values that underpin the National Minimum Standards, and place partnership working (with service uses and other stakeholders) at the centre. This is judged exemplary practice. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 2 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 4 25 3 26 3 27 4 28 4 29 3 30 4 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 4 3 3 4 4 Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 Requirement The registered person must ensure the Statement of Purpose is fully compliant with the National Minimum Standard and regulations. Original timeframe - 31/03/06 The registered person must ensure the Service User Guide is fully compliant with the National Minimum Standard and regulations. Original timeframe - 31/03/06 The registered person must ensure the Contract is fully compliant with the National Minimum Standard and regulations. Original timeframe - 31/03/06 Timescale for action 31/08/07 2. YA1 5 31/08/07 3. YA5 5(b)(c) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 27 No. 1. Refer to Standard YA7 Good Practice Recommendations The home needs to demonstrate that it takes more control over the formal care plan reviews. Five Ways DS0000047387.V338830.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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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