Inspection on 26/01/06 for Highfield Road

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Highfield Road 11/05/07

Highfield Road 29/06/06

Highfield Road 16/08/05

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 09/07/2008.

CARE HOME ADULTS 18-65 Highfield Road 29 Highfield Road Dartford Kent DA1 2JS Lead Inspector Helen Martin Announced Inspection 26th January 2006 10:30 Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Highfield Road Address 29 Highfield Road Dartford Kent DA1 2JS 01322 229600 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) DGSM Limited Miss Theresa Chambers Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: The home provides accommodation and residential care for up to 8 people with learning disabilities. Each service user has a single bedroom (bedrooms are arranged over 3 floors). Twenty-four hour supervision is provided. The premises are close to local facilities and to public transport. There is a car park at the rear. The house is owned by Hyde Housing and leased to DGSMencap Ltd. The premises has a small patio area at the rear. The manager advises potential service users and their supporters that the premises are only suitable for service users with good mobility. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on 26th January 2006 between 10.30 and 17.00. The visit included talking with the manager, a representative from Hyde Housing Association, support workers and residents. Some judgements about the quality of life within the home were taken from observation and conversations. Some records were looked at. A tour of the home and patio area was undertaken. Residents were happy to talk to the inspector about their life within the home. In addition comment cards were received as part of the inspection process from two residents, two relatives and four social and health care professionals. The majority of feedback received was positive. Some comments have been included within the main body of the report where appropriate. Highfield Road currently has seven residents, there is one vacancy. What the service does well: What has improved since the last inspection? Since the last inspection a potentially dangerous wall at the rear of the premises has been identified as belonging to a neighbouring property. A fence has been erected in front of the wall to avoid any potential risk to residents. Following an incident of a resident leaving the building at night, one fire exit has been alarmed. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 6 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. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Prospective residents know that the home will meet their needs, although they would benefit from some additional, easily understandable information before they decide to move in. Residents’ assessments and contracts could be better reflected in documentation. EVIDENCE: Previous inspection identified that, although the pre-admission information available for prospective residents and their representatives contained some useful information, it did not contain full details about the home’s services and facilities. Since the last inspection, the manager has reviewed the documentation available. Information is now contained within one document, designed to include the combined required details of the statement of purpose and service users’ guide. All the information is present with the exception of a copy of a standard contract including terms and conditions of accommodation, the complaints procedure and contact details of the CSCI. The information is not available in a format that would be easy for residents to understand. The manager said that they had received several referrals for the vacancy within the home. Residents benefit from an assessment prior to their admission to the home, to ensure that their needs can be met. The manager explained that although this was generally undertaken by the funding authorities, they would also assess a prospective resident before they moved Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 9 in. Pre-admission information is recorded in detail with the exception of the manager’s assessment. New residents are offered a ‘trial period’ to see if they like the home and to confirm that it is suitable for them. It was mentioned that the ‘trial period’ lasted three months followed by a multi-agency review and permanent contract with the home. Previous inspection identified shortfalls in the personal contract for residents; the manager undertook to review this and to have a revised contract available for any new residents. At the time of this inspection, the manager explained that although the contract had been revised, this was currently at the head office of DGSM for approval. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Residents are supported to make their own choices and decisions about their lives. Their changing needs could be better reflected in risk assessments. Residents would benefit from care plans that they could easily understand. EVIDENCE: A written plan of care for each resident is prepared from a pre-admission assessment. This reflects residents’ changing needs and goals. Care plans give staff guidance about action to be taken to meet the health and welfare needs of residents. Care plans include a range of issues, including health and social care. Those seen were completed in sufficient detail. Care plans are reviewed formally with care managers and on an ongoing basis. Daily notes are recorded in individual books. Care planning information is not available to residents in a format that is easy for them to understand. Residents are supported to take risks as part of maximising their independence and this is recorded, however some risk assessments are up to date, whilst some are not. The manager explained that they were in the process of reviewing the formats for all recorded risk assessments for residents. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 11 Residents are encouraged to make choices. They receive continuity of care by having individual key workers and one has an advocate. There is evidence that considerable attention is given to helping residents to make decisions about how to spend their time and to avoid the development of very rigid routines. Residents are involved as far as possible in decisions regarding the running of the home. They are involved in some cleaning, cooking and menu planning. A weekly meeting is held about choice of meals. Regular residents meetings are undertaken. Some residents described aspects of their aspirations and goals. These were very diverse as the group of residents have widely differing support needs. Information regarding residents is dealt with appropriately and documents are kept securely. Staff demonstrated an understanding of confidentiality issues. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Residents enjoy individual lifestyles, which include opportunities for social, educational and recreational experiences. They would benefit from the full cost of a holiday included in the contract price. EVIDENCE: Residents are supported towards independent living skills, dependant on their capacity, and also have the opportunity for personal, emotional and social development. Residents are treated as individuals who have different interests and aspirations. Activities and development opportunities are provided accordingly. Residents are part of the local community. Some residents are able to go out independently whilst some need support to do so. During weekdays residents enjoy attending day centres, participating in social events, activities that personally interest them or to further develop their life skills. Transport is provided. Activities available include a squash competition, trips to museums and cinemas, art and craft, cooking, games, drama, swimming, bingo, walks, healthy eating and computer lessons. Residents regularly enjoy attending Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 13 nightclubs. Opportunities are available for residents to undertake paid or voluntary work. One resident works in a garden centre and another as a gardener, they enjoy growing plants in tubs on the patio area. Residents spend time at the home in the evening, weekends and on the days when they do not attend day centres or work. They are able to relax watching television and videos or doing puzzles. Residents’ individual interests are encouraged. Support workers support residents with one-to-one time and trips out locally including the shops, pubs and for coffee. They are able to assist residents to continue their education or training and to continue taking part in planned activities. Residents are encouraged and supported with shopping, cooking, cleaning and laundry tasks wherever possible. Laundry and kitchen facilities are domestic in nature. Residents have access to the home’s patio area. Day centres provide support for money, road safety and sport. One resident is undertaking a cooking course and learning Japanese. Another is at college four days a week. Residents have front door and bedroom door keys to enable their independence. Residents are able to see their family and friends as often as they wish. Individuals can visit the home at any reasonable time and can be received in private, either in residents’ rooms or the quiet room. Some residents have very close connections with members of their families who visit regularly and take a close interest in their progress and wellbeing. Some visit their families on occasions. Residents have been able to maintain friendships outside of the home. All residents currently have the opportunity to go on holiday. The organisation pays for staffing and food costs but does not pay for accommodation. Residents enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. Residents are able to receive phone calls and visitors in private. Residents have meals in accordance with agreed menus, known choices and nutritional needs or preferences. Residents are supported in cooking and menu planning. A weekly meeting is held about choice of food and each resident can choose a meal. A written menu is developed from this. The manager demonstrated a good understanding of individuals’ likes and dislikes. The home provides special diets such as diabetic, vegan and low protein. Information, specialist cook books and records are kept regarding Phenyllketonuria (PKU). All residents that need it are supported by staff with any special diet. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 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, 19, 20, 21 Residents benefit from support which meets their individual needs. They would be better protected by improvement to the system for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. Residents are able to exercise choice and they have individual clothing and hairstyles. Staff have an understanding of the preferred routines of each resident. Residents have access to social and health care professionals. They are supported with any specialist appointments. Residents’ nutrition and weight is monitored and recorded and specialists are accessed on a regular basis if necessary. The social and health care needs of one resident were discussed in some detail at the time of inspection. It was mentioned that support had been gained from specialists such as a psychiatrist and psychologist and that a medication review had been undertaken. Changes have been made, to which the resident has reacted positively and this was evident during the inspection. No residents currently keep their own medication. Arrangements are in place for the storage and administration of medication. A monitored dosage system Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 15 of medication system is used. Storage is secure, although a designated controlled drugs cabinet is not used. MAR (medication administration record) sheets seen were completed appropriately. Those for a new resident are currently devised by the home; subsequent to the inspection, the manager stated that a second member of staff countersigns these as accurate. Subsequent to the inspection, the manager stated that a record of the administration of controlled drugs is maintained within the MAR sheets, although a designated logbook is not currently used. Records are kept with photographs of residents and a staff signature list. The manager said that GPs had approved the use of some homely remedies, although this was not evidenced in documentation. The manager demonstrated a good understanding of the challenges faced by residents regarding the death of a person close to them. Residents have been supported to come to terms with their loss according to their individual capacity. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 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 Residents’ views and concerns are listened to, although complaints made could be better reflected in documentation. They are protected from potential abuse, although minor additions to records would enhance this. EVIDENCE: Residents are at ease and confident talking with the manager and support workers who listen to their views and concerns. The home provides a written complaints procedure, a précis of which is displayed within the home. Residents have access to this in a format that they can easily understand. A record of all complaints is kept, although details of the investigation and outcome are not recorded. Previous inspection identified that residents are protected from potential abuse by the procedures in place within the home. The home follows the Kent & Medway Policy for Adult Protection. The manager demonstrated a good understanding of the procedures involved. The home hold small amounts of cash for some residents. This is kept securely. All money is stored individually and transaction records are maintained. Receipts are kept for all purchases made on residents’ behalf and they sign for the receipt of cash wherever possible. All residents have their own bank accounts with the exception of two, whose families deal with their finances. The financial system is audited regularly by the home and on a monthly basis by the head office of DGSM. The manager explained that DGSM has held appointeeship for one resident for some time. It was stated that no other options were viable. Residents’ personal possessions and valuables are Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 17 documented, although records are not signed or dated by the resident and/or their representative or staff. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Residents benefit from living in a clean, comfortable and homely environment, however this would be enhanced by some additional refurbishment. The premises are best suited to people with few mobility difficulties. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents have unrestricted access in the house and to the patio area. Residents benefit from living in a clean and comfortable accommodation. The premises are generally suitable for their current needs. The manager and the representative from Hyde Housing Association, who own the property, discussed long term plans for the future of the home. It is planned that a local purpose built premises will replace the current building. The house is maintained and decorated by Hyde Housing Association, which is audited on an annual basis. The manager explained that the communal areas and most residents’ rooms had been re-decorated about two years ago. Currently the home is in the process of renewing fixtures and fittings. New settees have been purchased and residents are currently choosing items for communal areas and their rooms, such as curtains and lampshades. It was stated that the kitchen would be replaced. The patio area at the rear continues Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 19 not to have been maintained as an amenity for residents. Although some plants are grown in tubs, a fly-tipped bed is awaiting removal by the local authority. The manager said that plans for this area would commence after April 2006. Since the last inspection a potentially dangerous wall at the rear of the premises has been identified as belonging to a neighbouring property. A fence has been erected in front of the wall to avoid any potential risk to residents. It was identified during the course of the inspection that the shower room, shower facilities and one bathroom floor are in need of refurbishment. It is planned to move the shower to a larger bathroom and provide an additional toilet. The manager said that work should commence by April 2006. Adequate recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides a lounge and dining area and a quiet room. All residents have their own rooms, arranged over three floors. Residents clearly like their rooms, which are all individual and highly personalised. They are able to choose the colour schemes and how their furniture should be arranged. Bedrooms meet service user’s needs and are well furnished. There are no lifts, specific environmental adaptations or disability equipment within the home. The manager indicated that some equipment would be provided if a resident’s review determined a need. Current residents have few mobility problems. It was stated that the new planned premises would have environmental adaptations. Discussion took place regarding the staff call system; currently call points are in bathrooms and toilets only. Previous inspection identified that the system should be extended to residents’ rooms. The manager said that currently residents continue to make their way to the locked door of the staff sleep-in room if they need assistance at night. It was said that an extension to the system had been requested from the Board of DGSM but that this had been declined. The manager explained that the system was tested weekly. Following an incident of a resident leaving the building at night, one fire exit has been alarmed. The manager assured the inspector that the other two fire exits are not a risk and did not need to be alarmed. External doors that are not fire exits are locked at night. The premises are clean and hygienic. There is a laundry room used by residents with support from staff. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Residents benefit from a sufficient number of staff who have a good understanding of their needs. Residents would be better protected by improvements to the systems for staff recruitment and training. EVIDENCE: Staff showed a good understanding of residents’ needs and the homes philosophy and values. Residents benefit from good support and interaction. Staff communicate well with each other. The home has a stable staff team. Induction and foundation training is provided and currently one member of staff is undertaking induction. All staff receive training in learning disability. Currently three support workers have obtained an NVQ level 2 qualification. Of the remaining three, two are undertaking an NVQ level 3 and one a level 2. One member of staff has a City and Guilds in Care. The staff training matrix was seen and although most core courses had been undertaken, there were some gaps. Training certificates are kept in staff files. The manager said that one newer member of staff who was awaiting a full Criminal Records Bureau (CRB) check had undergone a Protection of Vulnerable Adults (POVA) check and was currently appropriately supervised. It was stated that this individual did not presently escort residents outside of the home alone. Supervision records are kept within staff files. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 21 At the time of inspection, the number of staff on duty met residents’ needs. There are usually two staff during the day with one ‘sleeping-in’ at night. The manager works with the direct care of residents and has some ‘supernumerary’ days for management and administration. The manager explained that additional staff are provided for some evenings and weekends. Staff support residents with cooking, cleaning and laundry tasks wherever possible. No ancillary staff are employed by the home. Staffing hours are recorded on a roster. It was said that the home used little agency workers and had bank staff to cover any absences. A procedure is in place that aims to appoint suitable staff who can support the needs of residents. Staff files evidenced that pre-employment checks had been undertaken, although they did not include proof of identity. The manager said that questions asked and the answers given at interview would include a record of any employment gaps. It was stated that this, together with proof of identity and evidence of a POVA first check was kept at the head office of DGSM, and therefore was not available on the day of inspection. The home’s application form did not contain the facility for the self-disclosure of any cautions. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43 Residents benefit from a well run home, although their interests would be better promoted by a review of quality assurance, record keeping and written policies and procedures. EVIDENCE: The registered manager is a registered nurse with experience in the care of people with learning and physical disabilities in residential and clinical settings. She has achieved a DMS (Diploma in Management Studies). There is an open and inclusive atmosphere in the home. Residents were comfortable chatting and spending time with staff. Residents’ meetings are held monthly. Residents knew about the inspection and were happy to speak to the inspector about life within the home. The notice of inspection was displayed within the home. The Commission has received comment cards from residents, their representatives and social and healthcare professionals. Residents, relatives and stakeholders are able to Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 23 comment on the quality of service provided by the home through a system of questionnaires. Although the home receives informal feedback from the head office of DGSM, a system of formal analysis and feedback has not yet been developed. The home has comprehensive recorded policies and procedures that are available for staff. The manager explained that these are currently in the process of review by DGSM to ensure that they are specific to the home. Records are stored securely. Records seen were completed appropriately with the exception of staffing hours worked on the roster showed no surnames of individuals recorded, some risk assessments need updating and some recruitment records were unavailable for inspection. Accidents and incidents are recorded appropriately. Records and certificates indicated the regular testing and maintenance of systems and equipment within the home. The hot water temperature from one outlet was tested at the time of inspection and found to be appropriate to the touch. The manager assured the inspector that the surface temperature of radiators was not a risk to residents. Window restrictors are fitted upstairs, although it was stated that these would be replaced by a type that were not easily removed. COSHH (safety for storage of chemicals and cleaning materials) assessments have been undertaken. The manager stated that the home is financially viable and that this had improved significantly in the recent past with the increase in numbers of residents accommodated. Appropriate certificates for insurance and registration are displayed. The home’s business accounts were not inspected on this occasion. Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 3 3 3 2 2 2 2 3 Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 25 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&5 Requirement The registered person shall produce a written guide to the care home. In that, the reviewed combined statement of purpose and service users’ guide must include a copy of a standard contract including terms and conditions of accommodation, the complaints procedure and contact details of the CSCI. This requirement has been repeated from inspection dated 16th August 2005. 2 YA22 17(2) Sch4:11 The registered person shall maintain in the care home the records specified in Schedule 4: A record of all complaints made by service users or representatives or relatives of service users or by persons working at the care home about the operation of the care home, and the action taken by the registered person in Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 26 Timescale for action 31/03/06 27/01/06 respect of any such complaint. In that, the home’s record of complaints must include details of the investigation, outcome and any action taken. 3 YA34YA41 17(3)(b) Sch 4:6(f) The registered person shall ensure that the records referred to in Schedule 4 are at all times available for inspection in the home by any person authorised by the Commission to enter and inspect the care home: A record of all persons employed at the care home, including: Correspondence, reports, records of disciplinary action and any other records in relation to their employment. In that, proof of identity, POVA First checks and records of any gaps in employment must be made available for inspection in order to evidence a thorough recruitment procedure. 4 YA35 18(1)(c)(i) The registered person shall 30/04/06 ensure that staff working at the home receive training appropriate to the work they are to perform. In that, appropriate training must be provided for all staff to meet the needs of residents. 5 YA41 17(2)Sch4:7 The registered person shall maintain in the care home the records specified in Schedule 4: A copy of the duty roster of Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 27 31/01/06 27/01/06 persons working at the care home, and a record of whether the roster was actually worked. In that, details shown on the staffing roster must include the surnames of those individuals working at the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations It is recommended that the information contained within the combined statement of purpose and service users’ guide should be available in a format that is easily understood by service users. It is strongly recommended that, although funding authorities record pre-admission assessments, any additional assessments by the manager should also be recorded. Revised personal contracts should contain more specific information regarding the service provision for individual service users. In that, the manager explained that although the contract had been revised, this was currently at the head office of DGSM for approval. This recommendation has been repeated from inspection dated 16th August 2005. 4 YA6 It is recommended that care planning information is available to residents in a format that is easy for them to understand. It is strongly recommended that the manager complete their stated intention to update and review all recorded risk assessments. DS0000064649.V272143.R01.S.doc Version 5.1 Page 28 2 YA2 3 YA5 5 YA9YA41 Highfield Road 6 YA14 It is recommended that the cost of residents’ accommodation when on holiday should be included in the basic contract price. It is strongly recommended that, with regard to medication: • • A designated controlled drugs cabinet and logbook should be used. GPs’ approval of the use of some homely remedies should be evidenced in documentation. 7 YA20 8 YA23 It is recommended that records of residents’ personal possessions and valuables should be signed and dated by the resident and/or their representative and staff. The rear patio area should be developed as a safe and useful amenity for service users. This is particularly important in the absence of a garden at the premises. In that, the patio area continues to await development. The manager said that plans for this area would commence after April 2006. This recommendation has been repeated from inspection dated 16th August 2005. 9 YA24 10 YA24 It is recommended that, as service users on the 3 floors must make their way to the locked door of the room where the (sleeping) support worker is based at night, the call bell system should be extended to all bedrooms. In that, the manager said that an extension to the system had been requested from the Board of DGSM but that this had been declined. This recommendation has been repeated from inspection dated 16th August 2005. 11 YA24 It is strongly recommended that the refurbishment of the shower room, shower facilities and one bathroom floor should take place as soon as possible. It is strongly recommended that, with regard to staff recruitment files: 12 YA34 Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 29 • • 13 YA39 Records regarding questions asked and answers given at interview should be kept within the home. The application form should contain the facility for the self-disclosure of any police cautions. It is strongly recommended that with regard to quality assurance, a system of formal analysis and feedback should be developed. It is recommended that DGSM complete the review of policies and procedures to ensure that they are up to date and specific to the home. It is recommended that the manager complete their stated intention to replace existing window restrictors with a type that is not easily removed. 14 YA40 15 YA42 Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Highfield Road DS0000064649.V272143.R01.S.doc Version 5.1 Page 31 - 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. 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