Inspection on 20/02/07 for Kentmere Respite Service

This inspection was carried out on 20th February 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kentmere Respite Service 17/12/05

Kentmere Respite Service 01/09/05

Kentmere Respite Service 25/01/05

Kentmere Respite Service 31/08/04

Kentmere Respite Service 10/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Kentmere Respite Service 72 St Annes Road East Lytham St Annes Lancashire FY8 1UX Lead Inspector Mrs Jackie Riley Unannounced Inspection 20th February 2007 13:00 Kentmere Respite Service DS0000035974.V322067.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 Kentmere Respite Service DS0000035974.V322067.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. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kentmere Respite Service Address 72 St Annes Road East Lytham St Annes Lancashire FY8 1UX 01253 727212 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) Lancashire County Council *** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. The service should at all times, employ a suitably qualified and experienced manager who is registered with the NCSC. The home must be staffed in accordance with the Residential Staffing Forum guidance by 1st April 2004. Radiators should be fitted with thermostatic controls in service user bedrooms by 31 December 2003. Radiators should be guarded by 31 December 2003. Bedroom one should be redecorated by 31 December 2003. A lock should be fitted to the utility room door by 31 December 2003. A satisfactory periodic inspection report for the electrical installation at Kentmere must be provided to the National Care Standards Commission by 1st December 2003. 17th December 2005 Date of last inspection Brief Description of the Service: Kentmere is owned by Lancashire County Council and is operated by Lancashire County Social Services. It is registered with the Commission for Social Care Inspection (CSCI) to provide respite care for five people who have a learning disability. The home aims to provide a quality service for users of the respite scheme, which admits service users for short stays from one night up to two week periods. Most stays are planned but the service does have provision for emergency admissions. Kentmere is situated in a residential area of St Anne’s with easy access to local shops, amenities and public transport. The property is a dormer bungalow with all resident’s rooms on the ground floor with full wheelchair access. There is a well equipped bathroom area and separate toilet so that users of the service can expect adaptations for the benefit of those who are less mobile. Kentmere is committed to implementing the government’s strategy for the development of services for people with a learning disability Valuing People. Kentmere is represented on the Local Learning Disability Partnership Board and has a well-established relationship with the Fylde and Wyre Parents/Carers Forum, which is pro-active in the continued development of the services offered. The information contained in the home’s Statement of Purpose/ Service User Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 5 Guide is included in the information provided to prospective service users and their families. This written information explains the care service that is offered, the management and staff and what the service user can expect if he or she decides to stay at the home. It is written and designed to include a picture story so that all users of the service are not disadvantaged and can clearly understand the information provided. Information received prior to the visit (20/02/07) showed that the fees for an over night stay were £9.23, plus vouchers. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on a weekday over a three hour period. The inspection took place at the respite unit and included discussion with the manager of the unit, two staff members and one resident currently on short stay respite care. Two other service users intended to come into the home on the day but were unable to due to illness. As part of the visit the records of two service users were looked at in detail, staff records and a sample of other relevant records were also looked at. Prior to the visit the manager completed a pre-inspection questionnaire, which provided information about the service users, staff and other information, which assisted in assessing how the home was meeting the National Minimum Standards. Comment cards had been sent out prior to the visit and in total five were returned expressing the thoughts and views of how the service is run and how it affects users of the service and their relatives, representatives. Discussions took place with the manager and staff on duty and a tour of the home was undertaken. Communication with the service users varies greatly, due to individual constraints experienced, however evidence was gained through observations made of the very positive interaction with a service user in the home at the time. What the service does well: This home is well managed and the staff group are very committed and work together to ensure that service users enjoy their stay and have all their needs met. This was confirmed through comments received including “we have worked together for a long time and know what’s expected”, “we can deliver good quality care with the training the staff receive”. There was evidence of the staff team working closely with other professionals so that they know what the individual needs of service users are. Staff communicate well with each other and records seen confirmed there is a clear audit trail of information so that all service users needs are clearly identified and met. Staff spoken to commented on how they work well as a team, saying, “ we know the individual needs of service users as many have been coming for a long time”. Comments received from relatives were very positive. One comment was that, “ everything about the home is open and straight”, “a good well maintained and caring environment”. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 7 The visit was undertaken in a very warm, friendly atmosphere and a service user was seen to interact well with the manager and staff. Staff made sure the resident was part of the inspection programme at all times. Staff spoken to confirmed that they enjoyed their work and felt supported by the manager. Staff training is given priority to ensure that the staff obtain the experience and knowledge required to meet the different, changing and sometimes challenging needs of service users. What has improved since the last inspection? What they could do better: There must be some evidence of the homes intention in having a registered manager with the Commission for Social Care Inspection (CSCI). At the time of the inspection it was noted the previous registered manager left the post in January 2006, and that whilst there is a manager in post this is not a substantive post and there was no evidence of Lancashire County Councils intention in this matter. The controlled drugs record book should only be used if a controlled drug is administered so that this is a true record and can be audited. The home must make sure unannounced visits by the area manager is reported and a copy of the report sent to the Commission for Social Care Inspection (CSCI). Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 9 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 Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are clear to ensure the care needs of the service users are met. EVIDENCE: No service users are admitted to the home unless a comprehensive assessment has been carried out so that the home knows that they will be able to meet individual needs. The assessment information included evidence of the home working with other professionals who are involved in the care of users of the service either at home, in day centres or other residential homes. This type of mulitdisciplinary working makes sure the whole needs of the service users are looked at with essential information being shared so that there is a level of continuity in the delivery of care. Staff spoken to had a clear understanding of how the assessment procedures work and are part of the process so that they know how to meet the individual needs of the service user. As some of the needs of users of the service can be complex and challenging this process is seen as essential by the manager. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 11 The records of two service users who were in the home were looked at and were found to contain very comprehensive assessment information, which had been obtained before any admission took place. The written assessments seen confirmed there is involvement of the individual service user’s and in some instances their carers, so that everybody who needs to be is involved in the best interest of the service user. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and consistent care planning system in place, which ensures that the service users’ needs, aspirations and goals are met. EVIDENCE: Two service user files were examined and included detailed information about their personal, social, emotional, physical and healthcare needs so that the staff team know exactly what is needed to deliver good quality care to the individual. Staff spoken to said “we are involved in the care planning process for all users of the service”. Care plans are put together using this information with the involvement of the service user and their family. The service users are very much involved in all decisions that affect them and they are consulted at all times. Care plans show the level of support and assistance being provided so that staff have clear instruction as to what is needed for the benefit of users of the service. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 13 The manager and staff recognise the need for clear risks assessment thereby enabling staff to give support in encouraging service users to maintain their independence. There was evidence of how risk is determined for each service user. It was not seen to automatically deter service users from undertaking tasks which may be judged risky, it is based on calculated risk and consultation with others including family and other professionals, so that no service user is in any way disadvantaged. For some residents verbal communication is difficult. The staff at the home have endeavoured to look at specialist communication techniques so that no service user is disadvantaged. There were clear examples of where specialist communication systems have improved the quality of life of some residents resulting in increased confidence of the service user leading to participating in more social events. Staff spoken to stated they have received training in areas of specialist communication and this has proved positive in the knowledge base they have when providing care to service users with limited communication. Records seen are completed daily by designated staff and provide a clear picture of how the needs of individual users of the service are being met. Staff spoken to said “we know the importance of making sure the records are clear and give a true picture of how service users are spending their time”. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for development and community participation are addressed in the care plans, ensuring that people have a lifestyle that meets their individual needs and expectations. EVIDENCE: Through discussion with the manager and staff on duty it was clear that they understood their role in encouraging independence and promoting the service users’ personal development. One staff member commented, “ we go out with service users and do what they like to do, some like to go shopping, out to eat, or to attend an event, it’s really up to them”. Staff recognised the importance of working very closely with the relatives in order that the needs and wishes of the service users were met appropriately, especially as they are only in the home for a short period of time. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 15 Service users have a range of activities available to them, which included television, music, videos and board games. A resident was witnessed enjoying a foot spa treatment, which was evidently pleasing to them. The notice board is informative and provides any user of the service with information about what’s going on in the home and the wider community, so that they have the choice to be involved or participate in any way. Activities are arranged to meet individual wishes and abilities, so that nobody feels they are being disadvantaged. The management team and staff closely monitor the mixture of residents at any one time so that there is no conflict arising. A service user had been with a staff member shopping and out for lunch, which they had enjoyed. Nutrition was spoken about at length and it was noted the management team and staff are aware of the need for flexibility in providing meals to users of the service, as they can be so diverse. One staff member said “we’ve had training in this area because some of the service users have very special diets so we have a large stock of various food to meet their needs”. Service users are provided with a varied and healthy diet and a degree of choice. Details of individual preferences and dietary needs were recorded on the service users’ care plan. Information seen in regard to one service user indicated that they required a special diet and a specialist feeding technique. Staff spoken to said they had received specialist training in this area so that it can be well managed for the benefit of the service user. In addition medical guidance was available on the service user plan so that staff are fully informed. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that service users receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Medication procedures are safe to ensure the health and wellbeing of the service users. EVIDENCE: Two service user records were viewed and were found to contain comprehensive information about how the home meets residents physical and emotional needs. The records are well maintained and provide evidence the home works closely with the service user, their family and other professionals so that the staff know all about the specific needs of the individual. Staff spoken to had a good knowledge of the individual needs of users of the service, including their individual preferences, their specific medical needs and their personal choices and preferences. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 17 Throughout the visit, observations were made and confirmed the support of the staff to service users was good. There was evidence of a relaxed atmosphere with the staff member clearly having a good understanding of the individual needs of the resident including the likes and dislikes and how to effectively communicate with the resident. Staff spoken to and observations made confirmed the areas of privacy, dignity and independence are seen as essential in how care is delivered so that resident’s rights are recognised. There has been staff training in areas of equality and diversity so that staff understand the need to make sure no service users is disadvantaged due to any cultural difference. Examples were given on special diets and religious observation. Staff spoken to had a clear understanding of the areas of equality and diversity and this is transferred into how they deliver care. From the documentation seen, discussions with staff, comments received from relatives and observations made during the visit, evidence was gained that the service users were receiving the personal support they needed. Comments received from one relative indicated that they felt that the care and facilities were good and “the staff cant do enough”. The way the home manages medication is good and safe. All staff have recently attended medication training, which staff felt was really useful and gave them confidence in handling medication. As service users have short stays there is no additional stock of medication. Records seen and storage facilities seen are good and a clear audit is available so that the way medication is managed is safe for all users of the service. It is recommended the use of the controlled drugs record only records controlled drugs, which are administered when a service user is residing at the home, so that it is a true record. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for recording and reporting complaints are good so that people feel listened to. The Management team and staff have a good knowledge and understanding of safeguarding adult issues, which protect residents from abuse. EVIDENCE: The home has recently revised its complaints, concerns and compliments procedures, so that they are clearer and in an easy to use format. The entrance area to the home has all this information, which is also pictorial and on view. In addition to this information users of the service and their carer’s also receive a copy. This was confirmed from the surveys received prior to the site inspection. A staff member said “the information is much better now that it’s also in picture form, because many of our residents will now be able to follow it much more easily”. Comments received from relatives were very positive and confirmed that the staff acted upon any concerns that they brought to their attention. There have been no formal complaints made to the home or an external body in the last twelve months. There were a number of compliment cards and letters, which highly praised the management and staff at the home on the good work being carried out for their relatives. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 19 Staff were able to demonstrate that they were aware of individual behaviour changes and gestures that may indicate if a person was not happy and was not able to communicate verbally. Staff have attended training in safeguarding adults through Lancashire County Councils ‘No Secrets’ document. They are also attending training with the Learning Disabilities Award Framework (LDAF), and this should be completed for all staff by April 2007, so that they have an underpinning knowledge of the specialist needs in this area. Staff spoken to had a good working knowledge of the complaints and safeguarding adult’s procedures so that users of the service are safe. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a comfortable, homely and safe environment, equipped to meet the needs of those residents who are less mobile. EVIDENCE: The facilities provided are good and at the time of the visit the home was found to be warm, clean and free from any obvious hazards. All service user bedrooms are on the ground floor therefore access is easy. Mobility around the home for residents using mobility aids is also helped by the spacious hallway and large lounge, dining and kitchen area. A resident was seen to use all areas of the home without restriction during the visit. Comments from surveys prior to the inspection highlighted how they are satisfied with the homes environment. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 21 Bedrooms were seen to be individually decorated, some with specialist beds available for residents with more complex needs. All rooms had good lighting and furniture in place of a domestic nature so that each room is individual and homely. Residents are encouraged to bring personal items with them for their short stays so that their room is personal to them and helps them to feel they belong there. A large bathroom is equipped with a number of aids and adaptations for service users with more complex needs. There is consideration being given to re-design this room to make more use of the space available, which would benefit both service users and staff. There is a walled garden area at the rear, which is used for bar-b-cues during the summer months. It was seen to well maintained with some staff having particular interest in gardening. Examination of policies, records and information received from the home prior to the inspection confirmed regular tests to emergency lighting, fire procedures and extinguishers had been carried out ensuring the safety and protection of residents and staff is maintained. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The policies and procedures for the recruitment of staff are good ensuring the safety and protection of residents. Training for staff is excellent ensuring they have the skills and competences to carry out their roles. EVIDENCE: There has been little change in the staff team since the previous inspection. Staff records seen include, application and interview forms, individual identification and Criminal Records Bureau (CRB) disclosures. These completed documents ensure recruitment procedures are safe. References were in place to ensure the residents are protected. Some staff working in the home work in other local authority establishments. There was evidence the manager has in place information relating to their employment on the premises so that the essential information is always on hand. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 23 The registered manager is aware of the recruitment procedures and checks required by legislation, so that safe practices are in place. The manager said “ we work closely with the human resource team so that we know all staff go through all the necessary checks before they work in the home”. Staff on duty had worked there for a number of years but were aware of the importance of ‘fitness checks’ so that users of the service are protected. Staffing levels are flexible due to the purpose of the service, in that there are times when service user levels fluctuate and so staff are deployed in numbers to meet the needs of the service users at any one time. Staff spoken to said, “we work together as a team so that we cover the hours necessary for the service users”. Comments received through surveys included “they are always kind and courteous”, “I know I can always trust them”. Training records seen and discussion with the manager confirm the home has over 50 of care staff who have completed NVQ (National Vocational Qualification) level 2/3 in care, which ensure staff have the skills and competencies to provide care and support for the residents. In addition staff were seen to be highly motivated by the access to training in areas around the needs of the specialist service user group who stay at the home. Staff spoken to said “we can go on training whenever courses come up”, “we discuss what training we need with the manager in supervision” “we have just done safe handling of medication which was really useful”. The courses include, safeguarding adults, First Aid, Health and Safety, which all benefit both residents and staff. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and systems in place for the protection of staff and residents are good. EVIDENCE: The site inspection identified the home is run in a very relaxed and flexible way, which is advantageous to users of the service in that there is a warm and homely feel to the home in general. The manager commented on how the home should be a place where users of the service can feel safe and valued as an individual. This was also reinforced by the staff team who said, “we want service users to feel they belong here”. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 25 There was evidence of clear leadership, and staff confirmed that they felt valued in their role. The manager confirmed that she had a very committed team, which ensured that the needs of all individual service users could be met. Comments received from relatives confirmed that they were satisfied with how the home was managed and the support that they received. The health and safety of the service users was protected by the policies and procedures in place in the home. Evidence was seen which confirmed staff receive mandatory training in relation to these issues. The home has an annual development plan in place in order to continue to develop the home to ensure the safety and comfort of the residents. Regular staff and resident meetings are held and recorded and suggestions are carried out if agreed by both parties. There is a good system in place for monitoring the quality of the service, so that changes can be made when identified for the benefit of users of the service. Staff spoken to said they were involved in the review programme and make comments as and when they feel it necessary. There is also a formal system of gathering the views of all users of the service and this information is collated and used by the management team to identify any potential problems or areas of good practice. A card was seen commending the manager and staff team on the care they have delivered to a service user, which has had a very positive affect on the quality of life on that service user. It was evidence the manager and staff felt valued by the comments received. It was noted the manager registered with the Commission left the home in January 2006. Whilst it is recognised there is a current manager in post with a good level of experience and qualifications, there is a requirement for there to be a manager registered with the Commission in order to comply with the law. There must be evidence the home is receiving regular monthly unannounced visits from senior managers so that the home is being overseen and monitored by the registered provider. A copy of the monthly report must be sent to the Commission. Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 26 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 4 33 X 34 3 35 4 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 3 X 4 X 3 X X 3 x Kentmere Respite Service DS0000035974.V322067.R01.S.doc Version 5.2 Page 27 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 YA37 Regulation Requirement Timescale for action 31/05/07 2. YA37 8(1)(b)(iii) There must be a manager in post registered with the Commission, as the registered provider is not in day to day to day to day control of the home. 26 (2)(c) Thee must be evidence of the 30/04/07 home receiving an unannounced visit by a representative of the registered provider and a copy of the report sent to the Commission on a monthly basis so that the Commission has evidence of the homes operations. 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 YA20 Good Practice Recommendations The homes controlled drug record should only be used if a controlled drug is being administered, so that there is a clear record’s of the drug administered and by whom. It should not be used to record a controlled drug brought into the home by a resident, which is not used. DS0000035974.V322067.R01.S.doc Version 5.2 Page 28 Kentmere Respite Service Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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