Inspection on 02/11/05 for Kendall House

This inspection was carried out on 2nd November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kendall House 27/06/06

Kendall House 29/06/05

Kendall House 23/02/05

Kendall House 03/11/04

Kendall House 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Kendall House 15 Wesley Lane Warmley South Glos BS30 8BU Lead Inspector Paula Cordell Unannounced Inspection 09:30 2 and 14 November 2005 nd th Kendall House DS0000003370.V261813.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 Kendall House DS0000003370.V261813.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. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kendall House Address 15 Wesley Lane Warmley South Glos BS30 8BU 0117 9602508 0117 9566050 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) Mrs Marilyn Joan Clarke Mrs Julie Ann Smith Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 8 persons aged 18 - 64 years requiring personal care only 29th June 2005 Date of last inspection Brief Description of the Service: Kendall House is located in the village of Warmley approximately five miles from the centre of Bristol. It is in a semi rural location close to Warmley Common. There are shops and other community amenities within a mile of the home. The home is registered with the Commission for Social Care Inspection to provide accomodation and personal care to eight persons with learning disabilities aged between 18 and 64 years. Kendall House is one of four homes within the Manor House Organisation, three provide a service for adults with learning disabilities and one provides respite for children with a learning disability. The accommodation in Kendall House is on two floors. There is one shared bedroom. There is a spacious patio area accessed from the lounge area, which leads to the garden. The service values for the home are concerned with dignity, independence, participation, valuing people, equality, rights and working together. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over two days for a total of 6 hours. The purpose of the visit was to review the progress to meet the requirements and recommendations from the previous inspection and monitor the quality of the care provided to the individuals living at Kendall House. There has been one additional visit during this period from the Commission for Social Care Inspection’s pharmacist on the 11th October 2005. The outcome of this visit is included in this report. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the well being of the individuals living at Kendall House and the provider has sent monthly appraisals of the service. The inspector had an opportunity to meet with the manager, two staff and four residents. The inspector had an opportunity to tour the building and view a number of records including plans of care for three residents, staff records and records relating to the safety of the home. The inspector would like to take this opportunity to thank the staff and the residents for their warm welcome and assistance in the inspection process. What the service does well: The organisation has supported residents with a learning disability for many years. A number of residents have lived in the home since it opened eleven years ago. There is a strong commitment to provide residents with an individual life making full use of the community, living within a homely environment. Residents have a wide range of activities available to them. Seven of the residents have access to an external day centre in the community five days per week, demonstrating a commitment to providing residents with activities and occupation. Another resident has activities organised by the care staff on a daily basis. Residents are supported to build good links with families and friends. Residents are provided with a homely environment. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 6 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. Kendall House DS0000003370.V261813.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 Kendall House DS0000003370.V261813.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): 1,3,5 Residents had sufficient information about the service provided at Kendall House and to enable prospective persons to make a decision on whether to move to the home. Residents assessed care needs were being met. EVIDENCE: The home has a statement of purpose and a service user guide available to residents and their families. This met with the legislation and has been updated to include a statement on the reviewing of care plans in accordance with the National Minimum Standards. The home has a stable group of residents living in the home and the last person to move to the home was in June 1999. The home demonstrated a good understanding of the assessment process. Information in care records demonstrated that assessments were ongoing and care needs were being reviewed and updated as needs changed. There was a strong commitment that individuals are involved in the planning of their care and support needs. The home was able to demonstrate that they were meeting the changing needs of the residents living in the home including consulting with other professionals in the planning of the care. There is an outstanding requirement for the home to make an application to vary the conditions of registration to include one named person with dementia. The manager stated that the provider is in the process of sending the application. This has been extended with a short timescale to enable the home to comply. As part of this Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 9 requirement, staff had to attend training in dementia. Evidence was provided that staff were planning to complete a course the day after the inspection. Staff on duty demonstrated through discussion and observation that they had a good understanding of the needs of the individuals living in the home and how to meet them. A signed contract had been made available to residents, which met with the legislation. Kendall House DS0000003370.V261813.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 Resident were involved in the planning of their care, however the home must ensure that care plans are reviewed six monthly. EVIDENCE: Each person had a care plan and skills development plan that detailed the action taken by staff to enable residents to meet their care needs and achieve personal goals. Three plans of care were examined in detail. Information was person centred and written in the first person. Plans included how the person wanted to be assisted, how often, what the person did not like and risks that required assessment to ensure the individuals safety and protection. It was noted that care folders could benefit from information being archived at the last inspection. This process has commenced however the inspector noted that care plans from 2001 still remained in the care folders and to add to the confusion these were the first that were read. Two out of the three care plans had been reviewed at six monthly intervals. There was no date planned for the third, which should have been undertaken in August 2005. This is an outstanding requirement. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 11 Concerns were raised on the recording of daily information, which is recorded in one “day book” for all residents unless there were concerns about behaviour or health. At the time of the inspection two residents had their own daily record. In addition to the “day book” a diary was maintained to make a record of health and emotional wellbeing. Key workers were expected to transfer the information to care files on a monthly basis. The home should reconsider this present system of recording as it could compromise the privacy of information and it does not blend to person centred planning. The present system means that residents could not have access to their daily records. There was a strong emphasis in the home of the promotion of residents’ independence through systematic planning of care. A resident confirmed that the key worker system was in place describing how they had been supported to go Christmas shopping and other trips out during the year. Assessments and management of risks arising from care plans and safety in and out of the home had been undertaken. The inspector commends the service for the approach to risk assessments, which covered all activities undertaken. Documentation provided evidence that the risk assessment tool ensured the safety of residents but did not curtail or inhibit residents and encouraged independence and community participation. This is good practice. A resident stated that they have meetings in the home and are involved in the planning of activities, menu planning and choice of décor of their bedrooms. Staff, the manager and residents spoken with stated that there was a high level of involvement in household tasks. One individual stated that they assisted with the cleaning and the cooking. It was evident that they enjoyed this and felt valued and empowered. Another resident was involved in the weekly shopping trip and was seen assisting putting the groceries away. Records were held securely. Staff were aware of the need for confidentiality and had signed policies relating to this topic and data protection. Residents had evidently seen their care plans and resident signatures were included. Residents should have an opportunity to see their daily care records upon request however this would be difficult as a day report is maintained which includes comments about all the residents and would compromise the confidentiality of others. Kendall House DS0000003370.V261813.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): 11,12,14,15,16, Residents were encouraged to lead full and active lifestyles based on personal choice. EVIDENCE: Resident’s plans of care included information on how the home was meeting and developing social, emotional and independent living skills. Residents were evidently involved in the process. Residents have a structured plan of activities, which is complimented by social activities both in the evening and at weekends. Six of the residents have a five day placement at resource and activity centres, one attends a specialist day service for individuals with autistic spectrum disorder and another has activities organised by the home. It was evident that the residents were actively involved in the reviews of the placements to ensure that they are happy. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 13 A resident stated that they had been on a holiday with the home to Weymouth in a caravan. It was evident that they had enjoyed their holiday. In addition some of the residents had holidays with relatives and short weekend breaks. There was a strong commitment from staff in providing individuals with opportunities to experience every day life making full use of the community. Evidence was provided that residents had opportunities to go on trips to places of interest, attendance at a gym, swimming, meals out and shopping trips. It was evident from discussions with staff that residents would be supported to pursue any interests or hobbies. The home has a large garden shed, which is being used, as an activity area for arts and crafts and musical instruments. A resident confirmed that this was used in the evenings and at weekends. From reading care records it was evident that there was a focus on individuals being independent. Some of the individuals had control over their personal allowances and medication. This was clearly documented and safeguards were in place to ensure the safety of the individual. This is good practice. It was noted that the medication policy lacked guidance for individuals who self medicate. The manager stated that the provider is in the process of developing this. This will be followed up at the next inspection. Care records included information about contact with friends and families. A resident confirmed that they could telephone relatives. Relatives were evidently visiting the home. The home maintains a visitors record and visiting arrangements were included in the statement of purpose. Relatives were evidently being involved in the planning of care and attending review meetings. Resident’s rights were evidently protected. Residents had the right to privacy and identified with their bedrooms as their own space to relax and watch television. A resident confirmed that they had a key to their bedroom door and staff always knock prior to entering. This was observed during the inspection. Residents were seen accessing all parts of their home. The manager discussed with the inspector incidents where an individual required boundaries because of their condition and to assist with the reduction of their anxieties. These were documented and had been discussed with other professionals involved in the planning of care. This is good practice and demonstrated a multi-agency approach, which complimented the skills of the team. It was evident from talking with the manager there were concerns about an individual’s behaviour and how this was impacting on the other individuals living in the home. The manager stated that a placement review was being held to discuss the issues and the home was making a referral to the Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 14 behavioural team for assistance. This demonstrated a pro-active approach to the planning of the care. Menus were not seen on this occasion. A resident stated that they enjoyed the food. Residents confirmed that they could help themselves to drinks and snacks. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Resident’s personal and health care needs were being met. There are some actions that the home need to take to safeguard the individuals in the administration of medication. EVIDENCE: Care plans clearly documented the personal and health care needs of the residents. Systems for monitoring an individual’s wellbeing were in place and concerns about health were quickly addressed. Residents had access to other health professionals including a GP, opticians, chiropody, dentist and the community learning disability team. Individuals had a distinctive style demonstrated by their choice of haircut and style of clothes. Staff stated that as part of the key worker role individuals are supported to purchase clothes and toiletries. Staff have attended training in first aid and manual handling. The home has developed a comprehensive planner for training to ensure that periodic updates are undertaken. The home is informing the Commission for Social Care Inspection of reportable incidents as per regulation 37. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 16 Since the last inspection the home has had a visit from the Commission for Social Care Inspections pharmacist to review the recording of the medication and storage facilities. The home has responded to the requirements to ensure that medication is secure and locks have now been fitted to the surplus medication cupboard and the fridge where the insulin is kept. In addition all medication was now clearly labelled. The home presently re-dispenses medication to another container to enable residents to self-medicate. The manager stated that she is liaising with the pharmacist and weekly monitored dosage systems are being sent as from the end of the month rather than the present system of monthly. It was evident that the home was intending to comply with the requirement. The pharmacist made a recommendation that the home request copies of the patient information leaflets for all the medicines used. These were in place. It is recommended that the home request confirmation from the prescribing doctor on specific homely remedies for each individual, as this was not in place. The home has a medication policy. The manager stated that the provider is reviewing this to ensure that there is guidance for individuals who selfmedicate. Consideration should be given to the fact that by recording every resident’s medication administration in one book, individual medicine administration records could not go with the resident should they move. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 were not fully assessed. Residents have clear policies to enable them to raise concerns about the practices in the home and safeguard them. EVIDENCE: These standards were not assessed on this occasion. The home demonstrated compliance to the legislation and there were robust procedures for responding with complaints and allegations of abuse as seen at the last inspection. Since the last inspection staff have attended training in abuse in response to a requirement, some staff still have to attend however there was evidence that this was planned. The manager stated that this is now compulsory for all staff working in the organisation. Finances were checked. These were found to be satisfactory and safeguards were in place to protect the individual’s monies including regular checks, receipts and two staff signatures. The manager stated that a receipt is only obtained if spending is greater than £10. Discussion was had whether this was an appropriate amount and the manager has agreed to review this. It is recommended that where staff are responsible for expenditure a receipt is obtained for all expenditure. Kendall House DS0000003370.V261813.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, 27,28,29,30 Kendall House provides a homely clean environment, which meets the care, needs of the residents. However, this would be enhanced if the kitchen were refurbished. EVIDENCE: Kendall House is located in the village of Warmley. There are shops, a post office, a church and open spaces close by. The property is in keeping with the local neighbourhood and looked well maintained internally and to the exterior of the home. All areas of the home were maintained to a high standard. All areas were clean and tidy, safe and comfortable. There were sufficient bathing facilities and toilets situated in the home. Bathrooms were clean and comfortable. All shared space was domestic in style and consisted of an open plan lounge/dining area and a kitchen. The kitchen was a well-used area of the home with residents congregating around the large table on their return from their day placements. The kitchen is looking old and worn, two of the Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 19 cupboards were broken. The manager provided evidence that this was being dealt with as part of the planned maintenance. It is recommended that the kitchen be updated and replaced. There was a spacious mature garden, which had a patio area with seating. To the rear of the property is a hobby room and a green house. Residents and staff said that the hobby room is accessed on a regular basis. This was well stocked with music equipment, games including a pool table and art and craft materials. A number of the residents said they enjoyed the support staff gave to them with their art and crafts and hobby sessions. There were appropriate aids and adaptations to meet the needs of the individuals living in the home. It was evident from conversations with the manager and records seen that the home would consult with the appropriate professionals if any aids or adaptations were required to improve the lifestyles of the individuals living in the home. Kendall House has two bedrooms and a bathroom situated on the ground floor, however, the home would not be suitable for an individual with physical disabilities due to the stairs that access the garden and the lounge/diner. Kendall House DS0000003370.V261813.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, 33,34,36 Competent staff support the residents. There is a commitment to providing a trained workforce which links to the care needs of the residents. EVIDENCE: The staff duty rota provided evidence that the home was staffed according to the assessed needs of the individuals living in the home and the statement of purpose. The home is staffed by two staff during the day, three staff during the evening and one member of staff sleeping in to provide individuals with contact in the case of an emergency. In addition the inspector saw the home exceeded this to enable individuals to go out in the local community and attend clubs. Staff were knowledgeable about the care needs of the individuals living in the home and there was a commitment to providing individualised packages of care and enabling the residents to be as independent as possible. Staff records were reviewed. All staff recruited since the last inspection had the appropriate information to demonstrate that a thorough recruitment practice had taken place. The home was able to demonstrate that they had met the requirement to ensure that two references and a criminal record bureau check is in place prior to offering a position to new staff. Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 21 There was a comprehensive induction in place, supervision and ongoing training. The home has responded to ensure that staff undertake training in dementia. Out of a team of ten staff, two staff have an NVQ in care, which is the manager and the deputy both have an NVQ 3 in care. A further two staff are enrolling to complete an NVQ 2 in care and a further person enrolling to complete an NVQ 3 in care. The manager is in the process of completing an NVQ 4 in care and management and has successfully completed the NVQ Assessors Award. The manager stated that the organisation is committed to provide a trained workforce including NVQ but many of the staff are new to the role of carer at Kendall House and the home is focusing on ensuring a comprehensive induction is completed. The manager stated that she is requesting an external assessor to assist to enable the home to have at least 50 of the workforce trained to NVQ standard. This will be followed up at the next inspection. Staff had signed policies and procedures and the General Social Care Council’s code of conduct. Staff stated policies are discussed as part of the induction and discussed at regular intervals at staff meetings. Evidence was provided that meetings occur on a monthly basis. Various topics are discussed demonstrating that there is good open communication within the team. Kendall House DS0000003370.V261813.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): 27,38,42 Residents’ benefit from living in a well-managed and safe environment. There is an open culture and inclusive atmosphere in the home. EVIDENCE: Mrs Julie Smith is the registered manager. She has worked at the home for the past ten years and was successfully registered as the manager in April 2004. She is in the process of completing an NVQ 4 in care and management. Staff spoke positively about the management structure and the support networks in place in the home to enable them to fulfil their roles as care staff. The home had a relaxed and friendly atmosphere with a focus upon promoting residents’ independence that was facilitated and encouraged by the manager. All staff spoken with stated that they enjoyed working at Kendall House. There were good systems of communication between staff including daily handovers, records and meetings both for the staff and the residents. This Kendall House DS0000003370.V261813.R01.S.doc Version 5.0 Page 23 demonstrated that there was an open culture and support mechanisms both for staff and the residents. Health and safety monitoring was in place both by the manager and an organisational Health and Safety Manager. It was evident that these robust systems protect both staff and the residents. Fire records were in order and included checks on the equipment, a record of fire drills and the training of staff. These were at the appropriate intervals. A fire risk assessment was in place. Staff had attended training in health and safety and this was on an annual rolling programme with updates planned throughout the year. Policies and procedures were in place relating to health and safety including risk assessments. These had been kept under review. There is one requirement relating to records. To ensure that plans of care are updated at the appropriate intervals, and one recommendation to ensure that where information is no longer current that this is archived. There was no evidence that the home was not financially viable. Kendall House DS0000003370.V261813.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 3 X 3 X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kendall House Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000003370.V261813.R01.S.doc Version 5.0 Page 25 No 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 YA3 Regulation Care Standards Act Requirement The home must apply for a variation to the conditions of registration to include the category of dementia (DE) for one named person. (Unmet requirement 29/7/05) Care plans to be reviewed at least six monthly. (Unmet requirement Risk assessments to be kept under review at least six monthly. The policy for self medication must be reviewed to ensure that medicines are given to the residents in the safest manner avoiding staff re-dispensing medicines whenever. Timescale for action 14/12/05 2 3 4 YA6 YA9 YA20 15 (2) (b) 15 (2) (b) 13 (4) 13 (2) 14/11/05 14/01/06 01/12/05 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 YA6 Good Practice Recommendations Archive information, which is no longer current to the plan DS0000003370.V261813.R01.S.doc Version 5.0 Page 26 Kendall House 2 YA10 3 4 5 YA20 YA20 YA28 of care of the individual. For the home to review the recording of daily information to ensure it respects the individual’s rights to confidentiality and where this information can be shared with the individual. For the home to maintain an individual record of medication of administration. For the individuals to have an individual protocol on homely remedies which the prescribing doctor has agreed. 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