Inspection on 15/11/07 for Kerwin Court

This inspection was carried out on 15th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kerwin Court 09/12/08

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

CARE HOME ADULTS 18-65 Kerwin Court Five Oaks Road Slinford Horsham West Sussex RH13 0TP Lead Inspector Rebecca Shewan Key Unannounced Inspection 15th November 2007 10:00 Kerwin Court DS0000069845.V349556.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 Kerwin Court DS0000069845.V349556.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. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kerwin Court Address Five Oaks Road Slinford Horsham West Sussex RH13 0TP 01403 799160 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) colin.carpenter@birt.co.uk The Brain Injury Rehabilitation Trust Mr Colin James Carpenter Care Home 23 Category(ies) of Physical disability (0) registration, with number of places Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: 2. Either. The maximum number of service users to be accommodated is 23. Date of last inspection N/A Brief Description of the Service: Kerwin Court is owned and operated by the Brain Injury Rehabilitation Trust (BIRT) and is located on the outskirts of Horsham. The home is registered to provide care and accommodation for up to twenty three younger adults. The aim of the home is to provide intensive rehabilitation therapy to service users who have medical/physical/behavioural/cognitive/functional deficits following an acquired brain injury. The home is arranged as one main building consisting of sixteen single occupancy bedrooms and two flats, whilst there are five self contained ‘independent living’ bungalows in the grounds (to the front of the main building). The home and bungalows are detached properties that have been purpose built and are set in their own grounds, a short distance from the local town of Horsham. There are well maintained gardens on three sides of the main house, that are easily accessible to service users. There is generous parking to the front of the main house. The town centre with its shops and access to bus and rail travel is approximately two miles away. Other local amenities are also within a short distance to the service. The main house has level access on the ground floor, with access to the first floor via a lift. Grab rails, toilet riser seats, hoists and other adaptations are installed throughout the main home. All sixteen bedrooms and both flats have en-suite facilities, consisting of a walk-in shower, WC and hand washbasin. In the main house there are two additional bathrooms of which one is an assisted bath. The bungalows consist of a lounge, kitchen, bedroom and bathroom (with a walk-in shower, WC and hand washbasin). BIRT has a contractual arrangement in place with the Ministry of Defence (MoD), which allows a number of the homes beds to be utilised for service personnel. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 5 The range of fees charged is from £1907 to £2719. Additional charges are made for toiletries and additional activities outside of the programme. Potential new service users can obtain information relating to the home via the internet – on both the BIRT website and CSCI website, Care Managers, Placing Authorities, by word of mouth or by contacting the home direct. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 15th November 2007. Incident reports, and the home’s Annual Quality Assurance Assessment (AQAA), held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took five and a half hours. A tour of the whole home was undertaken and the Registered Manager, four staff and two service users, were spoken with. Records such as care plans, staff files and medication records were also viewed. Thirteen service users were accommodated at the home at the time of the inspection. Ten service user surveys were also sent to the home of which seven were returned. Comments received included: ‘The food is excellent and the Chef is brilliant.’ ‘The programme is too rigid!’ ‘The Manager is approachable and listens to us.’ ‘I like working here, it’s has a very community feel about it’ What the service does well: The home ensures that pre- admission assessments are carried out on all new and potential service users with only those who needs can be met, being admitted to the home. The home promotes service users rights and participation, as these are essential elements of their individual rehabilitation programme. Activities and social/community contact are arranged according to service user choice. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. The health needs of service users are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to service users in such a way that promotes and protects service user’s privacy and dignity. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to service users. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 7 There is an efficient complaints procedure in place and the homes processes and staff training should protect service users in the event of an allegation of abuse. The home has a staff team that have the necessary skills and experience to the meet the needs of current service users. Staff training is on going and is appropriate to the level of needs of current service users. The management and administration of the home is good, with evidence of consideration being given to service user’s and/or relatives opinion. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kerwin Court DS0000069845.V349556.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 Kerwin Court DS0000069845.V349556.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides detailed information to prospective service users and their family/representative. There are appropriate processes in place for assessing potential new service users, with services being offered to only those service users whose needs can be met. EVIDENCE: The Service User Guide and Statement of Purpose are provided to all new and existing service users. These documents were found to be comprehensive in detail. A service user commented in the service user survey that as they did not have access to a computer, ‘it would have been nice to see more pictures in the brochure’. The home’s Registered Manager and/or Consultant Clinical Neuro Psychiatrist carry out pre- admission assessments. Records inspected showed that Pre admission assessments are carried out on all new and potential service users. The home also obtains a copy of a care management assessment from a placing authority where this exists. The Registered Manager confirmed that Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 10 potential service users would be declined if necessary, if it were deemed that the home could not meet their needs. Trial visits are arranged as a matter of course and generally consist of a visit to the home during the day, to enable potential service users to obtain a flavour of the home, have a meal and meet with other service users. Of the three service user files viewed it was evidenced that service users have individual Contracts in place, which is signed by the home, the individual and/or the placing authority. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 11 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, 8, 9 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service user care plans are comprehensive in detail and are suitable for meeting service users needs. Service users are encouraged to have control over their lives and to exercise choice and be independent in their decisionmaking. The home has good processes in place for recording and handling of monies that they hold for service users. Risk assessments are satisfactory and encourage service user independence. EVIDENCE: Three service users individual care plans were viewed and it was noted that these were comprehensive, detailed in content and covered all aspects of service user’s needs and allows the assessor to gain a good overview of individuals medical, social and personal care needs. Care plans are devised with service users involvement and in a format that is service user friendly. An initial period of six weeks assessment is conducted on each service user. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 12 Following the six week period, a multidisciplinary meeting is held with the service user and/or their family/representative. Care plans are then reviewed at this stage, with all parties agreeing the goals and aspirations that the service user can achieve during their rehabilitation programme. Care plans viewed reflected service users wishes and detailed how the home assist service users to make decisions about their lives. The rehabilitation programme is designed around meeting the service users physical/medical needs, as well as personal aspirations and goals that are within the service users limitations. Advocacy services are available for those who require them. ‘Personal allowance’ accounts are maintained by the home, which allow service users to buy toiletries and other essentials. The home has a ‘Unit Bank’ which enables service users to access their accounts at specified times. Records of all accounts were found to be well maintained, whilst separate wallets were utilised for storage of individual accounts in the homes safe. The Registered Manager reported that the home does not take any responsibility for any of the service users other finances and that most service users have family, friends or representatives who protect their financial affairs. Service users are encouraged to participate in the day to day running of the home. Weekly service user meetings are held. Each service user is aware of their structured rehabilitation programme and staff assist service users, where necessary, to conduct their activities/chores/rest periods/skills learning at the agreed specified time. Suitable risk assessments were noted to be in place. On occasions due to the nature of the service provided, it becomes necessary to restrict/limit choices and decisions. Where this is the case, for example in relation to externals outings/activities that re not part of the agreed rehabilitation programme, agreements are reached with service users and contracts are written. The need to balance rights against health and safety is kept under constant review. Behavioural charts are also maintained and any limitations that behaviours may have on an individual service user are recorded and actioned. Information that is held by the home, in relation to service users, is well maintained and stored in a locked cupboard within a locked room. Service user may have access to their records upon request. The home has a Confidentiality Policy in place. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users participate in an activities programme that is rehabilitative, rewarding and stimulating. Service users individual programmes are varied and provide ample opportunities for personal development. The home provides good social, cultural and recreational facilities, including specialist diets to service users, with service user’s choice and wishes being respected. EVIDENCE: Each of the service users has a programme of the activities that they participate in. Service users are encouraged to attend college courses/night classes. Activities that service users participate in include, gym, swimming, therapy sessions, external activities such as shopping, walks, day trips and life skills. Programmes are designed to keep service users active through the day but there is ample leisure time in the evenings and weekends. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 14 At the present time there are no service users in active employment. The Registered Manager reported that a newly appointed staff member will proceed with this matter and access the local resources available, in order to provide service users with the opportunity to gain employment. Staff were observed assisting service users with the life skills to enhance their interviewing techniques and how to compile a resume. Service users are able to access the local community as part of their programme and as part of their leisure time. Service users religious wishes are observed and arrangements can be made to encourage service users to attend places of worship. Discussions with the Registered Manager highlighted that although the current service users fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and service users. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Service users have access to all areas of the home to ensure that they have freedom of movement. Though this does not apply to the flats or bungalows as these are accommodated privately, which is respected by all staff and service users. Permission to these areas is sought prior to entry. Staff were observed knocking service users bedroom doors prior to entering. Service users are called by their preferred choice of address. Service users, with or without assistance, conduct household chores/tasks. Such tasks are appropriately assessed and agreed in the service users individual programme. The promotion of independence is an essential element of the rehabilitation programme, therefore responsibility for housekeeping tasks is positively encouraged. The home’s menus are devised on a weekly basis. Service users spoken with stated that there is ‘a good variety of food and that the menus are varied.’ All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and service users guests are also welcome to have meals at the home. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity and attractively presented. Mealtimes were observed to be unhurried. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are offered a good provision of health care and personal support by the home. Medication procedures ensure that all necessary precautions are taken to ensure errors do not occur and that medications are stored and administered safely. EVIDENCE: Personal support that is offered is given in such a way as to promote and protect service users privacy and dignity, whilst promoting their independence. Of the seven service user surveys received 3 service users responded ‘yes’, two responded ‘usually’ and two responded ‘sometimes’ to the question that asks ‘Do staff treat you well?’ One service user spoken with and one service user survey commented ‘that staff can sometimes be impatient if you are not quick enough’, whilst one service user survey commented that ‘the staff are all very helpful and friendly’. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 16 From the records sampled and from discussions with staff, it was evidenced that the health needs of service users are well met with evidence of good multi disciplinary working taking place. The Registered Manager said that service users could be registered with a GP of their own choice or with one from the local surgery. Service users are encouraged to attend the GP surgery were able and home visits are conducted when necessary. The home has an ‘in house’ Consultant Clinical Neuro Psychiatrist, Psychologist, Physiotherapist Speech and Language Therapist and two Occupational Therapists, Dietician and Audiologist appointments are made via the GP or the hospital. The home has access to pressure relieving equipment when required. The home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. There were no Controlled Drugs being held by the home at the time of the inspection. Service users who are able, are assisted to self medicate and it was noted that suitable risk assessments were in place to encourage independence with medication taking. From the service user files sampled it was evidenced that service users death, dying and critical illness wishes were found to have been recorded. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect service users in the event of an allegation of abuse. EVIDENCE: The home has a comprehensive complaints procedure in place. The home has received one complaint since it was registered in May 2007. The home’s Manager is currently addressing the complaint. Two service users were asked whether they knew about the homes complaint procedure and both responded that knew who to complain to. Of the service user surveys received, to the question asked ‘Do you know who to speak to if your not happy?’ six responded ‘yes’ and one gave no response. To the question that asks ‘Do you know how to make a complaint?’ three responded ‘yes’, one responded ‘sometimes’, one responded ‘never’ and two gave no response. Both Criminal record Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Staff have attended training in the Protection of Vulnerable adults within the last six months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. There has been one Safeguarding Alert in the last six months. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides accommodation for service users that is appropriate, well equipped, safe, hygienic and odour free, whilst infection control procedures are adhered to at all times. EVIDENCE: The location and layout of the home and bungalows are suitable for their stated purpose. The home and bungalows have been purpose built and were commissioned and registered in May 2007. All areas of the main house, including the garden, are accessible to service users. Service users spoken with said that they liked their bedrooms and that the communal areas of the home were comfortable. All bedrooms (those in the main home including the flats) and bungalows are single occupancy and have en- suite facilities. Bedrooms are spacious and have Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 19 been designed to accommodate service users who require the use of specialist equipment and wheelchairs. Bedrooms also have the necessary fixtures and fittings in place. Service users are encouraged to bring in their own furniture and may personalise their rooms, in accordance with Fire and Safety requirements. Each bedroom is lockable, with strategies in place to override the locking mechanism should it be necessary in an emergency. All sixteen bedrooms, both flats and the five bungalows have bathroom facilities that consist of a walk-in shower, WC and hand washbasin. In the main house there are two additional bathrooms of which one is an assisted bath. The main house has a number of shared spaces that include one large lounge, two smaller ‘quiet’ lounges, an activities room, a large dining area and two kitchenettes for service users to maintain independence in cooking and are also utilised for life skill training. There is also a main courtyard, which is the homes designated smoking area. Additionally there are therapy rooms and a ‘Unit Bank’ – where service users have a designated place and time for accessing their ‘personal allowance’ accounts. From the tour of the premises it was evident that both environmental adaptations and specialist equipment is in place. The main house has a lift, enabling access to the first floor. All areas of the premises are accessible to service users. There is a call bell system in place that encompasses the entire premises. There is an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records and by staff spoken with. Staff were observed adhering to infection control procedures. The main house and bungalows were clean and odour free throughout. There is a daily cleaning schedule in place. Laundry and sluicing facilities were also noted. Of the service user surveys received, to the question asked ‘Is the home fresh and clean?’ five responded ‘always’ and two responded ‘sometimes’. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current service users. Staff are appropriately trained and supported to conduct their jobs effectively. EVIDENCE: There is a clearly defined staff team and service users are aware of staff roles and responsibilities. From the three staff files viewed and from the four staff spoken with, it was evident that staff have clearly defined job descriptions in place. Staff spoken with knew the aims and values of the home and stated that they ‘work as a whole team to achieve these’. A competent staff team meets the service users needs. There is a staff rota in place, which details staff designations and hours of working. The home has a permanent staff team of twenty one Rehabilitation Support Workers (RSW), the Registered Manager, six clinicians (Consultant Clinical Neuro Psychiatrist, two Occupational Therapists, Physiotherapist, Psychologist, Speech and Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 21 Language Therapists), an Assistant Manager, three Administrative staff and three ancillary workers. Five carers are trained in National Vocational Qualification (NVQ) level 2 in care. This was confirmed in the homes AQAA and from the staff training records viewed. Three staff recruitment files were viewed and it was evidenced that these files contain all items required under the Care Homes Regulations 2001. Some of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. The home has an Equal Opportunities policy in place and is an equal opportunities employer. Three individual staff training files were viewed and it was evident that staff training in Induction, Health & Safety, Food Hygiene, Control of Substances Hazardous to Health, Protection of Vulnerable Adults, Infection Control, Fire Safety and Medication. Additional Training is also provided for: Basic Brain Injury, First Aid, BARS (Behavioural measurements and recording) and NVQ’s. The staff induction-training package was viewed and this was found to be comprehensive in content. Staff spoken with stated that they are regularly supervised, both formally and informally. Records viewed confirmed this. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 & 43 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to resident’s choice and opinion, whilst the health, safety and welfare of service users and staff is protected at all times. EVIDENCE: The Registered Manager has many years experience of working with younger adults and also has a qualification in Social Work and Management. Service users and staff spoken with said that the Manager was friendly and approachable. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 23 The Registered Manager operates an ‘open door policy’ and promotes and open and inclusive atmosphere. The home has utilises the BIRT Quality Assurance Procedure. The Registered Manager reported that a Quality Assurance audit was due to take place within the near future, as the home has now been fully operational for the past three months and that it is hoped that the audit will convey how the home is currently meeting it’s aims and values. Regulation 26 visits are carried out by the Registered Providers. Records of monthly staff and weekly service users meetings were viewed and there was evidence of actions taken to address any issues raised. Policies and procedures are in place and are accessible to both staff and service users. Service users may have access to their records upon request. All records are stored and maintained in accordance with the Data Protection Act 1998. From the AQAA provided by the home it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (where applicable) had been carried out within the last six months. The financial viability of the home was assessed prior to its registration in May 2007, therefore such documentation and records were not assessed during this inspection. Kerwin Court DS0000069845.V349556.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 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations That consideration is given to making the Statement of Purpose less detailed in content and formatted in a userfriendly manner. Kerwin Court DS0000069845.V349556.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Kerwin Court DS0000069845.V349556.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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