Inspection on 16/10/06 for Kent House

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kent House 24/10/08

Kent House 15/02/06

Kent House 31/08/05

Kent House 17/02/05

Kent House 04/10/04

Kent House 20/10/03

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

CARE HOME ADULTS 18-65 Kent House Kent House 1 Haslerig Close Aylesbury Bucks HP21 9PH Lead Inspector Joan Browne Unannounced Inspection 16th October 2006 09:30 DS0000022984.V308840.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 DS0000022984.V308840.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. DS0000022984.V308840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kent House Address Kent House 1 Haslerig Close Aylesbury Bucks HP21 9PH 01296 330101 01296 394580 kh@birt.co.uk 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) The Disabilities Trust Mrs Christine Wood Care Home 22 Category(ies) of Physical disability (22), Physical disability over registration, with number 65 years of age (6) of places DS0000022984.V308840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 22 residents with a physical disability, two of whom are over 65. Date of last inspection 15th February 2006 Brief Description of the Service: Kent House is a specialist care home for adults with acquired brain injury. It is registered to provide rehabilitation and long-term care for twenty-two service users from various parts of the country. The Brain Injury Rehabilitation Trust, which is a charitable organisation, owns the home. The home is located in Aylesbury close to shops, pubs the post office and other amenities. The building is purpose built and was first registered in 1994. All the homes bedrooms are single with en suite facilities. There are four bungalows adjacent to the home for those service users who have greater degrees of independent living skills. They comprise of lounge and dining rooms, bedroom, kitchen area, bathroom and toilet. The home has a garden area, which is wheelchair accessible. There are seating arrangements where service users who smoke like to gather. The current weekly charges are £1320.00. Additional charges are made for hairdressing, toiletries, newspapers and magazines. DS0000022984.V308840.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 inspection of the home that took place on 16 October 2006. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of the previous inspection noted. Comment cards were received from eleven service users, ten relatives three health and social care professionals and the general practitioner. During the visit service users and three relatives who were visiting were interviewed. Overall they were satisfied with the provision of care. A tour of the premises was undertaken and care records were examined. The care of two service users was case tracked from their original contact with the home to the care that they are now receiving. Care practices and the home’s approach to quality and diversity issues were observed. What the service does well: Service users visit the home prior to admission and their needs are thoroughly assessed. Rehabilitation plans to promote independence are in place for individual service users and they are reviewed three weekly. Care plans seen incorporate service users likes and dislikes. Service users’ health care needs are well met with evidence of multidisciplinary working. The home employs its own clinical psychologist, physiotherapist and occupational therapist. Regular reviews take place to ensure that the care plan reflects changing needs and agreed changes are recorded and implemented Risk assessments are in place, which outline service users’ assessed vulnerabilities. Monthly service users’ meetings are held, which indicate that service users’ views are sought. Service users are well supported by staff and their privacy and dignity are maintained. The home has its own transport facilities this indicate that service users are able to access activities in the wider community. DS0000022984.V308840.R01.S.doc Version 5.2 Page 6 The home promotes advocacy this indicate that service users are able to contact an advocate who will act in their interests. The home has a relaxed calm atmosphere. Interaction between service users and staff was positive with humour and lots of smiles. Methods for measuring quality assurance are in place. Systems are in place to ensure that service users’ health, safety and welfare are protected and promoted. Service users are able to access a wide range of social and leisure activities in the community. Service users’ bedrooms provide single room accommodation. All service users have an allocated key worker and receive key working time weekly to discuss issues. The home has good relationships with other health care professionals. What has improved since the last inspection? The home ensures that risk assessments are reviewed regularly to reflect current changes in individuals’ care needs. The home has developed continent assessment forms to manage individuals’ continence problems more effectively. The use of tippex correction fluid in care plans has ceased. The home has developed person centred care plans to ensure that service users are provided with the appropriate care. The home has developed a service user committee group to ensure that service users are involved in any decision making in the home. The home has improved service users’ folders to ensure that information relating to service users’ care needs is easily accessible. The home has updated its quality assurance plan to ensure that service users’ views under pin all self-monitoring review and development by the home. The home has reviewed its fire risk assessment to ensure that safety in the home is promoted. DS0000022984.V308840.R01.S.doc Version 5.2 Page 7 Some areas of the home have been redecorated and floor coverings replaced with wooden floor to enhance its appearance. New kitchen and laundry equipment has been purchased. 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. DS0000022984.V308840.R01.S.doc Version 5.2 Page 8 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 DS0000022984.V308840.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to the service. Prospective service users’ needs are fully assessed prior to admission to ensure that the home could meet their needs. EVIDENCE: The home has a good pre-admission process in place. All prospective service users are assessed by the home’s clinical neuro-psychologist. When a placement is offered the prospective service user would usually visit the home over a period of time to determine if the placement would be appropriate. A further rehabilitation and needs assessment is undertaken and any potential restrictions on choice would be discussed and agreed with the service user during the assessment. DS0000022984.V308840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans are drawn up with consultation with service users to reflect their needs and reviewed regularly to ensure that the home was meeting the assessed needs. The home ensures that service users have access to an independent advocate if required to help them to express their views. EVIDENCE: There were four service users who were using the services of an advocate to help them with expressing their views and lead their lives as they choose. During the inspection the advocate was visiting service users and he was spoken to. He was confident that the home was providing quality care to service users. As part of individuals’ rehabilitation programme the home has systems in place to support service users who are able to manage their finances, which are reviewed regularly. As part of promoting some service users to have an independent lifestyle detailed risk assessments have been developed. These are reviewed regularly DS0000022984.V308840.R01.S.doc Version 5.2 Page 11 in a multi-disciplinary forum. Some service users are expected to provide their own meals once or twice a week. Others are expected to go out on their own using public transport. Staff were supporting a particular service user who was living independently in the community. The home has a missing person’s procedure and expects all staff to be familiar with it and to respond appropriately to any unexplained absences by service users. DS0000022984.V308840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home would support service users to take part in fulfilling activities inside and outside the home. This indicates that service users are encouraged to choose their own lifestyle. Service users are provided with nutritious meals in pleasing surroundings. EVIDENCE: From discussions with staff members it became apparent that some service users were on vocational work placements. Others were attending college to improve their numeracy, literacy and information technology skills. One particular service user spoken to was looking forward to taking up a voluntary placement at the local hospital. As part of service users’ activity programme they are encouraged to take part in activities in the local community. The home has its own transport facility to transport service users on shopping trips or outings if they wished to. As part of individuals’ rehabilitation programme they are expected to use local transport or taxis to the town centre. Service users spoken to said that they often visit the local leisure centre, shops and pubs. Several service users said DS0000022984.V308840.R01.S.doc Version 5.2 Page 13 that they attend the local church weekly and are made to feel welcome by the congregation. All service users are on the electoral register and are encouraged to exercise their political rights if they wished to. Staff support service users to maintain links with their family. Some service users spend weekends with their family or go away on regular family holidays. The home is in the process of establishing a family support group. Through work and leisure activities service users are able to make friends and meet people. The home has policies and procedures in place to enable service users to develop and maintain intimate personal relationships with people of their choice if they wished to. As part of some service users’ rehabilitation programme to promote independence they are expected to clean their rooms, do their laundry and prepare their meals several times a week. One particular service user spoken to said that he enjoyed keeping his room clean and tidy. Staff are expected to knock on service users’ bedroom doors and wait for a reply before entering. All service users have been issued with keys for their bedroom doors. However, front door keys are only issued to some service users subject to their assessed needs. Mails are delivered to service users unopened and assistance with opening is given if required. Service users preferred form of address is recorded in their care plans. Individuals can choose to be alone or to participate in activities. The home is a no smoking home. Those service users who wish to smoke use the garden. The home has set meal times however, meals can be flexible if required. Snacks and hot and cold drinks are served throughout the day. Vegetarian and Halal meals are also provided. Lunch was observed and consisted of cottage pie, yoghurt and fresh fruit. There were a variety of fruit juices. Tables were appropriately set with cutlery, condiments and serviettes. Lunch seemed a relaxed and social activity. Lunch was sampled and it was tasty. Service users spoken to confirmed that lunch was always tasty and portions were adequate. Those service users who needed assistance with feeding or prompting were provided with assistance in a sensitive and discreet manner and with the appropriate eating aids such as plate guards. DS0000022984.V308840.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements are in place to ensure that service users’ personal and health care needs are met. However, staff’s medication recording practice need to be more robust to minimise any potential risk to service users. EVIDENCE: Service users’ preferences on how personal care should be provided are documented in their care plans. Any specialist support and treatment are documented in the care plans. Personal care is provided in private and requests for gender care would be granted if requested. Individuals’ preferences of rising and retiring are recorded in their care plans. Those service users who require assistant with moving and handling are provided with the appropriate aids and equipment to assist them. Service users spoken to said that they choose their own make up, hairstyle and what clothes they wished to wear. Service users’ attire was clean and tidy with attention to detail. All service users are registered with a general practitioner who visits the home weekly. Specialist National Health Service treatments can be accessed via the general practitioner. Arrangements are in place to ensure that service users receive regular dental, optical and podiatry check ups. The home gets support DS0000022984.V308840.R01.S.doc Version 5.2 Page 15 and advice from the district nurse, continence adviser and the diabetic specialist nurse. The medication administration record (MAR) sheets were examined. No unexplained gaps were noted. However, it was noted on a particular service user’s MAR sheet that staff had signed daily for a particular tablet that is administered to the individual once weekly. There was no written explanation on the MAR sheet to indicate that the entries were recorded in error. This was discussed during the inspection. Staff’s recording practice need to be more robust to minimise any potential risk to service users. It was noted that management plans had been developed for PRN medication. There was evidence that the pharmacist carry out regular auditing of the home’s medication. The manager said that the home’s pharmacist was reviewing the home’s medication training pack with a view of it achieving accredited status. DS0000022984.V308840.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has policies and procedures in place to ensure that service users’ views are listened to and that they are protected from any potential abuse. EVIDENCE: No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Information submitted on the pre inspection questionnaire indicated that the home had received one complaint, which appeared to have been dealt with appropriately. Service users spoken to said that if they had a complaint they would report it to the manager or their keyworker and they were confident that it would be addressed appropriately. No allegations of abuse have been reported to the Commission about the service since the last inspection. The home has policies and procedures in place to protect service users from any potential abuse. Staff spoken to said that they had undertaken training in the protection of vulnerable adults. Staff were confident that any suspicion or allegation of abuse would be investigated appropriately and demonstrated a good understanding of adult protection. The home has systems in place to ensure that service users’ finances are handled appropriately and there are written records of any transaction made. DS0000022984.V308840.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users live in a comfortable and safe environment that is well maintained to protect their safety. EVIDENCE: The home is located in Aylesbury close to shops, pubs the post office and other amenities. All bedrooms are single occupancy with en suite facilities and provide adequate space for individuals. Those bedrooms viewed during the tour of the premises were personalised with family pictures, paintings and mementoes. They were clean, tidy and free from odours. Service users spoken to said that they liked their bedrooms and liked living in the home and that they felt safe. The home has a planned maintenance and renewal programme for the fabric and decoration of the premises. Information recorded on the pre-inspection questionnaire indicated that several bedrooms had been decorated. Floor coverings in corridors had been replaced and new curtains purchased. DS0000022984.V308840.R01.S.doc Version 5.2 Page 18 A fire officer inspected the home in May 2006 and all requirements made in relation to fire safety have been complied with. It was noted that a new fire panel was recently installed. The environmental health officer inspected the premises on 16 February 2006 and all health and safety matters were found to be satisfactory. All areas of the home were clean and hygienic on the day of the inspection. The home has good systems in place to control the spread of cross infection. The laundry room is situated away from where food is prepared. There is a red bag system in place for separating soiled laundry and to reduce the risk of cross infection. The walls in the laundry room are impermeable. The washing machines have the specified programming ability to meet disinfection standards. It was noted that a new dryer had been recently purchased. DS0000022984.V308840.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has recruitment procedures in place to ensure that staff are vetted appropriately to care for service users. However, these procedures would need to be reviewed to reflect current changes in the regulations. The home has an ongoing training programme in place to ensure that staff are appropriately trained to meet service users’ needs. EVIDENCE: The recruitment records of three staff members were examined. All had completed an application form and had two references. However, in one of the files seen there was not a reference from the most recent employer. It was noted that one of the staff member’s had previously worked in a position, which involved contact with children. There was no written verification (so far as reasonably practicable) of the reason why the individual ceased to work in that position. This was discussed with the manager during the inspection. There was also no recorded evidence on references seen to indicate that the authenticity of references had been checked. All files contained criminal record bureau clearances, statements of fitness of health and terms and conditions of employment. Recent photographs to confirm proof of individuals’ identity were not on file. It is acknowledged that pictures of staff members are displayed in the home. However, to fully comply DS0000022984.V308840.R01.S.doc Version 5.2 Page 20 with the Care homes Regulations it is strongly recommended that individuals’ photographs be kept in staff’s files. On the day of the inspection two potential staff members were interviewed. It was noted that service users were invited to meet with the applicants. The home manager said new staff members are issued with copies of the general social care council codes of conduct when they take up employment. Staff appointments are subject to a three and five month probationary period. The home has a training and development plan in place. The manager and her senior staff team carry out in- house training. Individuals’ training needs are discussed and identified in staff supervision. The home’s training matrix indicated that all staff receive a structured induction training, which includes training on equal opportunities, disability and equality. Mandatory training in health and safety, fire awareness, first aid, food handling and hygiene, protection of vulnerable adults, moving and handling, epilepsy, safe handling of medication and other training link to service users’ needs are regularly provided. Rehabilitation support staff were working towards achieving the national vocation qualification (NVQ) in direct care at level 2. There is a multi-cultural staff team working in the home who were over the age of eighteen. DS0000022984.V308840.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has audit systems in place to ensure that service users are consulted regarding all aspects of their care. Health and safety records seen were in order and should indicate that service users’ health and safety are protected. EVIDENCE: The home is managed by an experienced manager who is a registered nurse and holds the registered manager’s award in care and management at national vocational qualification (NVQ) level 4. The staff said that the management atmosphere was open and that the manager was approachable. The manager ensures that the staff team are aware of the aims and objectives of the home and its policies and procedures by reviewing them on a regular basis and discussing them at staff meetings. Senior staff are expected to undertake training to assist them in enhancing their knowledge and skills in the day-to-day operation of the home. Regular reviews for service users are undertaken and service users’ contracts are kept under review. DS0000022984.V308840.R01.S.doc Version 5.2 Page 22 The manager regularly updates her knowledge and skills by attending training updates and legal workshops. The home has an annual development plan based on a systematic cycle of planning, action review that reflects aims and outcomes for service users. The home is also accredited with the investors in people award and is working towards achieving a further accreditation known as Commission on accreditation of rehabilitation facilities (CARF). The recent results of the home’s yearly surveys indicated that 95 of service users were happy with the provision of care. Relatives and stakeholders were 100 satisfied. The home was addressing the areas that service users felt needed to improve. Twenty-five comment cards were received in connection with this inspection. Eleven from service users, ten from relatives and three from health and social care professionals (including the GP) and one from a care manager. All service users respondents said that they liked living in the home, felt well cared for, felt well treated by staff, and knew who to complain to if they were unhappy. All liked the food as well. These views were confirmed in conversations with some service users during the course of the inspection. Relatives were equally positive in their views: all said that they were welcome at any time, could visit service users in private. There was one concern that a relative was not kept informed of important matters. Most relatives were aware of the complaints procedure, and were satisfied overall with the care provided. Additional comments included: ‘Very happy with standard of care father receives. ‘Quite happy with the help and support our son gets from Kent House.’ ‘The home provides excellent care for my sister.’ Health and social care professionals were also positive. They reported good communications with the home, that there was always a senior member of staff on duty to confer with. That the staff demonstrate an understanding of service users’ care needs, that medication is appropriately managed, and that specialist advice is incorporated into care plans. Additional comments included: ‘All staff are very helpful. We liaise on a regular basis’. Overall, the comment cards demonstrated a high level of satisfaction with the home. The home has good systems in place for the regular maintenance of technical systems and equipment. These include: Gas checked 6 April 2006, central heating checked 29 March 2006, electrical wiring checked 9 March 2006, PAT (Portable Appliance Testing) 9 August 2006, hoists 19 May 2006, 17 February 2006 and July 2006. Temperature check, water-heating check for compliance with Legionella is carried out weekly. The registered manager said that an independent consultant carried out a fire risk assessment of the building and as a result a new fire panel had been DS0000022984.V308840.R01.S.doc Version 5.2 Page 23 fitted. Fire training was carried out on 28 February 2006. Fire drills are carried out at random. The emergency lighting was checked on 24 August 2006. An environmental health officer visited on 16 February 2006. DS0000022984.V308840.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X DS0000022984.V308840.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA34 Regulation 19 Requirement The registered manager must review the home’s recruitment procedure to comply with current regulations and guidance. Timescale for action 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA20 Good Practice Recommendations It is strongly recommended that the registered manager should ensure that care plans are reviewed weekly as identified in individuals’ needs assessment. It is recommended that the registered manager should ensure that staff’s medication recording practice should be monitored to ensure that any potential risk to service users is minimised. It is strongly recommended that the registered manager should ensure that recent photographs of staff are kept in their files to confirm proof of identity. 3 YA34 DS0000022984.V308840.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford, OX4 2SU 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 DS0000022984.V308840.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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