Inspection on 22/11/07 for May Lodge

This inspection was carried out on 22nd 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 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

May Lodge 02/08/06

May Lodge 01/02/06

May Lodge 31/10/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 May Lodge Barrow Hill Sellindge Ashford Kent TN25 6JG Lead Inspector Lois Tozer Key Unannounced Inspection 22nd November 2007 10:15 May Lodge DS0000065349.V352619.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 May Lodge DS0000065349.V352619.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. May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service May Lodge Address Barrow Hill Sellindge Ashford Kent TN25 6JG 01303 813926 01303 814974 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) CareTech Community Services (No.2) Ltd Post Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: May Lodge is registered to provide care to six people who have a learning disability aged between 18 & 65. The aim of the Home is to provide a service to younger adults, within the age range 18 - 25 who have a diagnosis of autistic spectrum disorder or Asperger’s syndrome. The home is a detached bungalow, surrounded by its own gardens, and comprises of 6 single bedrooms; three with full en-suite facilities, three with toilet and wash hand basin. Two communal bathrooms with WC are positioned in easy reach for all. For communal use are a lounge, with TV and video facilities and a dining room, with a music system. The home has a large kitchen and a separate laundry. A large garden, to the rear of the property has a picnic table, a variety of recreational items and some developing plant boarders. The home is in easy walking distance of the village of Sellindge that has a shop, pub, and community centre and is on a direct bus route to the towns of Ashford and Hythe. The fee range starts from a base rate of £1350:00. Individual support needs are assessed and a further top up to the base fee is applied. Further details can be obtained from the home, as can previous inspection reports. May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key site visit took place on 22 November 2007 between 10:10 am and 5:10pm. The manager, Nigel McCann, people who live at the home and staff assisted with the process. Mr McCann is currently applying for registration. Five people live at the home at the moment. Comment cards were sent to three people, unfortunately, these were not in a suitable format. We spoke to four residents who were able to give various degrees of feedback. Two residents discussed life at the home using picture communication aids. Four staff comment cards were returned. Organised and spontaneous activities were taking place throughout the visit, and observations formed part of the evidence collected. Comments on surveys sent to two relatives were received after the visit. Mainly positive feedback was given, including ‘…provides a warm, supportive environment where young people can grow and develop. Supported to be involved in all aspects of their lives. The staff are dedicated and respectful. Difficulties have been handled professionally’. Some areas for improvement noted were ‘A lack of co-ordination between the company and the home. Repairs are started and not finished, bills sent to the service users are unclear. Staff need more training on autistic spectrum disorders, as there is an underlying lack of awareness (to this condition)’. The manager and a resident showed us around their home. The manager pointed out where changes are planned, where maintenance was needed and where improvements had taken place. The inspection process consisted of information collected before, during and in the few days after the visit to the home. Some of the information seen were assessment and care plans, person centred ‘essential lifestyle’ plans, medication records, duty rota, communication packs, training information, staff records and the menu. What the service does well: People know that new residents will have a full assessment and will be compatible with the group of people living at May Lodge. They are having a say in the assessment process. Individual plans are designed for people who live at the home to use and enjoy. They are written in an easy read way with lots of pictures that are meaningful to each person. May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 6 People get to choose the shape of their lifestyles, through the Person Centred Planning (PCP) process. Residents feel confident to seek staff support. Staff and residents work alongside each other doing daily jobs. People have a good laugh at the home. Staff and residents enjoy each others company. Staff have got to know people well, and are committed and dedicated to offer support and opportunities to people. What has improved since the last inspection? What they could do better: People have good relationships with staff, but need a complaints procedure that is easy to read and use. This might have to be in several formats, depending on the needs of the people living in the home. Some maintenance issues take a very long time to get sorted out. People’s personal bathrooms have been in an unacceptable condition for months, even through advocates have complained on behalf of the individuals. Other issues May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 7 have been reported through the ‘visit by registered provider’ system, but still have not been sorted out. A much quicker system needs to be put in place. 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. May Lodge DS0000065349.V352619.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 May Lodge DS0000065349.V352619.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): 2 Quality in this outcome area is good. Prospective residents can be certain that their needs and aspirations will be thoroughly assessed and they will have a big say in this process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last two people to come and live at the home had extensive assessments. These had been conducted by the manager and deputy and had recorded the individual’s views on what they wanted from the home. Detailed information about best ways to support the individual had been obtained, including parents, key workers and care manager input. One resident told us about visiting the home before they chose to live here, and that they really wanted to come to May Lodge. They said it was a good choice. Another person told us that a new person had visited, and they were excited to see them again soon. The manager is aware that the depth of information around personal communication needs to improve. This is so any training needs can be sorted out before the person becomes resident and complex communication systems can be used without delay. May Lodge DS0000065349.V352619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent. People living at the home can be sure that they will be given every opportunity to make their needs and choices known. They are supported to take risks as part of a full lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Decision-making and person centred planning (PCP) is very well supported. Four of the five people living at the home have had a PCP planning meeting, which has involved the people most important to the individual being involved. The type of decisions and achievements being made has surprised the staff who have known people for quite a long time. Changing the environment and looking at risk assessments differently has resulted in everyone having freer and safe access to the kitchen. Locking the door is only permitted at specific times, but mainly when a 1:1 cooking activity is taking place. The manager said that the first PCP meetings were to really get a new way of thinking up and running. There are clear goals to make May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 11 improvements for the next ones, based around people’s decision-making style and preferred ways of communication. Key workers are supporting a particular person to construct boxes; to help them put their questions and answers in so they remain involved in the process. Information will be collected in advance so it does not put the individual under unbearable pressure. The manager and staff said that some of the recording required by the company is ‘bitsy’ and is difficult to manager. They said they hope to make a simpler, more effective system to complement the PCP work that will involve each individual more. Other risk assessments are enabling and have been written up for the individual. They are very simple and specific, presented in colours, with pictures involving the person. The manager said that risk assessing should open doors, not close them. Staff feedback supported this view. The team having a creative and positive approach to helping people develop. Staff are pleased with the PCP way of working, and people living at the home are clearly having excellent support to increase and improve on their skills. We observed people seeking activities with staff around chores, and staff recognising these non-verbal requests. This means people are really given meaningful and natural choice making opportunities. May Lodge DS0000065349.V352619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent. Through commitment to person centred planning (PCP), people really are getting the lifestyle they want and developing new, useful and varied skills. Staff possess skills that help people empower themselves and this has reduced ‘challenging’ behaviours. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a wide range of activities taking place in and away from the home. Using PCP meetings, people have said what they find interesting and what they want out of life. These have been put into picture form and people are able to point at the things they would like to do in the coming week(s), or the next day, or even the next few hours. Some people like to go to college, or do gardening, while others enjoy swimming, art, computer, bowling or adventure walks. Holidays in the summer gave people a chance to try out new things, like horse riding, which have become continued interests. Many of the May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 13 activities take place in the local community, and some are at specialist services. People said they like the pub and shopping. One person said they wanted Christmas Dinner at the pub, which is being planned for. Through PCP work, people are saying what they want from relationships. The manager said there is lots of work to do around relationships, and making sure the home supports diversity by conveying open-mindedness in a way resident’s understand. Each person has said what her or his perfect day is, and this is clearly documented in the PCP. Staff record that they support people to have the lifestyle they have chosen, and this has reduced challenging behaviour – respecting their rights. The manager and team have fully revised the way risks are assessed and this has improved opportunities for people to take greater responsibility in their lives in a fair and co-operative way. People say they love living at May Lodge. They smiled and understood the planning process and three people happily pointed out, or described, things they have got up to over the last 3 months, using the home’s photo-album. People are much more involved in cooking and preparing meals. Although the majority of hot cooking is done by staff, people are actively encouraged and supported to participate in every meal. Staff said a person who was quite isolated before has become more tolerant of socialising since their support plans were reviewed. Records showed that this was the case. Residents choose what is on the menu, and staff make sure that it is healthy and balanced. Staff aim to improve the way that choice takes place, so everyone can have a good say. Staff feedback showed that they are keen to get people involved using pictures, cut-outs from magazines and other developmental work through projects. May Lodge DS0000065349.V352619.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People know that staff will support their personal and healthcare needs with dignity and help improve on independence through developmental support, prompts and encouragement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and team currently use the consistent approach for supporting people with their personal care. This is a documented account about how people are to be supported, based on their known abilities and support needs. The manager said he hopes to take this in a more person centred direction, supporting people to learn about their health and take a greater degree of independence. Two people said that staff always knock on their doors and ask before they help them with things. Other observations showed staff helping people to look after their laundry and operate the washing machine with minimal support prompts. Information from relatives about individual preferences has been used, and their advocacy has helped staff give the right sort of support. May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 15 Health wise, people have had ‘health action plan’ assessments. These need to be dated to make it clear about when people have said they have particular health needs (or not). The manager said more work needs to go on around these, and at the moment, two systems of health recording is used. Staff feel this is heavy on time and not an effective way of looking at a person’s needs. All medication is stored and administered centrally at present. It is done so safely, and staff have had training and competency assessment to make sure they keep doing it well. Discussions about people having more responsibility for their medication took place. The manager felt that supported administration, with the right types of assessments and teaching plans, would be achievable for several, if not all, people. The system of dealing with errors, returns medication, ‘as required’ medication and ordering is clear. There are medication journals for reference in place, but no up to date information, such as the ‘BNF’, which should be in place for all staff to use and updated regularly. May Lodge DS0000065349.V352619.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. People feel safe and know that the staff team will help them ‘speak up’ if they have a problem. They would benefit from a easy to use procedure that is always available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been 3 adult protection concerns raised in the last 12 months. All were raised in relation to service users demonstrating or saying that they were unhappy. In retrospect, the action that should have taken place to make people safe and feel secure was slow in coming. The manager was new to post at this time and appreciates this. All staff have reviewed protection of vulnerable adults (POVA) procedures, and had training. The action taken by the manager, when made aware of the issues, was swift and appropriate. All alerts have since been closed. People say that they feel that they can tell any staff their worries. Some people have specific communication difficulties associated with autism, and this means staff need to be careful to record how behaviours may be representing distress. Staff told us through questionnaires and conversation that they knew what their duties were and how to go about protecting people. They also said that communication systems needed to be better, and they wanted to use pictures more. Staff training has given people good May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 17 opportunities for being creative with communication, which has a very positive effect for the service users. We discussed having an easy complaints procedure that people who use pictures might, with help, understand. The manager said this could be developed, and is a recommendation. In the meantime, people have close relationships with staff, who record through ‘talk-time’ systems any concerns that may come up. As the support given to people has been agreed with them, the level of ‘challenging’ behaviour has decreased. Simple changes, such as unlocking doors has had a powerful effect. The ethos of the home is in line with the Mental Capacity Act 2005 of assuming people have the ability to make decisions for themselves, with the right sort of support. Any restrictions are now debated through a decision making process with this Act in mind. The manager hopes to support people to take more control over their personal finances over the next 12 months. Records held in the office show that people’s finances are looked after safely. May Lodge DS0000065349.V352619.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, 30 Quality in this outcome area is adequate. Some parts of the home are very nice, homely and comfortable, but maintenance issues are taking an unacceptable length of time to fix. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is generally clean, comfortable and homely. Bedrooms are personalised and suit individual’s lifestyles, but the following issues stop people enjoying their home as they should be able to. Some areas we were shown (hallways and en-suite bathrooms) have been mended badly or have taken an unacceptable length of time before getting fixed. One person is still waiting for their en-suite to be sorted out, and this has resulted in a complaint in May 2007 from a relative, which is fully substantiated, yet has not been fixed. The manager and staff said there is a real problem with maintenance, and the representative of the registered provider has reported this time and again through the monthly visits. Because of these issues, hygienic systems cannot be maintained for people. Staff really support people to keep their house clean and tidy, but it is the big things that the manager has no financial control over May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 19 that let the service down for the residents. Staff gave feedback that they have reported loose paving slabs and the need for an outside light so people can use the back garden in the dark safely. This has not been addressed either. Staff also fed back that an additional area for people to have quiet time (that was not their room) would be beneficial. The organisation did say when the home was refurbished, extended and re-registered that this would be planned for, but has not been developed. May Lodge DS0000065349.V352619.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): 32, 34, 35 Quality in this outcome area is good. People who live at the home know that the staff have the right skills and training to support them well. They know that they will be protected through the recruitment process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a staff team of 15 people, and has no vacancies. Four people have an NVQ qualification (27 ), and a further 3 are currently undertaking this. The deputy manager will start NVQ 4 training in January 2007. Many of the team have been working at the home for over 18 months, giving the people who live in the home a real chance to form relationships and get continuity in support. All four people who were in said or indicated that the staff were good. They confirmed they were kind, and that they trusted them. We observed staff giving people enough time and the right sort of support to do things themselves. Staff did not take over, but used the minimum support necessary to help people achieve their aim and goal. Staff have adopted empowerment and PCP approaches with enthusiasm. Feedback from a relative said that ‘staff could do with more autism training’. They said that ‘while staff do listen to what is being asked, there seems to be an underlying lack of May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 21 awareness of autistic spectrum disorder. More in-depth training in this area should be planned into the forthcoming training schedule. Some written feedback from 3 staff received said ‘Get monthly supervisions, weekly if requested, management always approachable’ ‘We have had CRB checks’ ‘Very good induction, everything that I needed to know was covered in detail’. ‘The service is brilliant at being fun & friendly and meeting service users needs. Everyone is happy most of the time’. ‘I have the right support now, before I was a little scared about things, but can do my job well now’. ‘Training is improving, I will attend 3 courses during November – Diet and nutrition, Adult protection and Promoting empowerment and PCP’s’. Records showed that recruitment was protecting people by getting police and POVA checks and references in place before new staff started. A ‘Skills for Care’ standard induction is in place. People living at the home have a say in who works with them, and get to meet, show around, do an activity and give feedback before a person is offered a post. As well as feedback, records showed that training was being provided based on people’s assessed needs. Recent communication training has had a great impact on the team, with feedback from staff asking what could improve being summed as ‘Develop ways of offering more choices and experiences for clients through developing communication skills’. Staff felt very supported by the management of the home and that they were developing skills that were being rewarded by service user success. The manager conducts monthly staff meetings and uses this time for reflective practice, which has been shown to be a very effective training method. May Lodge DS0000065349.V352619.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, 39, 42 Quality in this outcome area is good. Service users can be certain that the manager will develop the service in a way that fully involves them. The organisation must support the manager better by providing adequate maintenance facilities and other pre-scheduled safety checks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has had 17 years experience managing residential services. He trained as a RMNH, although has not been registered as a nurse for many years. He is currently undertaking the NVQ 4 in management. He has just applied for CSCI registration, which is good news for the ongoing stability of all living and working at the home. The outcomes to service users show that he May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 23 has the skills and competencies to run and manage the home in the best way for people. The people living at the home know that their views are taken seriously and that they lead development and changes in the home. The manager and team are using information from residents to change the way they work and make life more accessible for people. The manager has a clear plan in his head about the shape the service will take. It would be really inclusive if this were presented in visual form that people can see and comment on. The organisation has recently appointed a Quality Assurance team, and this will hopefully sort out some of the issues that are outside of the manager’s control, such as maintenance. At the moment, this system lets people down, as described in the environmental standards above. Generally, the health and safety checks and measures of the service keeps everyone safe. A review of fire risk assessments has taken place with an appropriately trained person. All but one certificate are up to date, the manager is chasing up to get the hard-wiring checked in the coming weeks, and will advise CSCI when this is booked. Staff have a wide range of health and safety training, and records show that this has been effective. May Lodge DS0000065349.V352619.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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22 (1, 2) Requirement Timescale for action 01/02/08 2 YA24 23 (2, a, b) So everyone knows what to do and what to expect, develop an ‘easy to use’ person centred complaints procedure. This may need to be in more than one format. So that people living at the home 01/02/08 can enjoy an environment that remains homely, a plan of improvement with timescales that are realistic and respect the people living at the home needs to be drawn up and kept under continual review. 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 So all staff can find out the up to date information about medicines and drugs, a British National Formulary pharmaceutical guide should be purchased and replaced at least yearly. DS0000065349.V352619.R01.S.doc Version 5.2 Page 26 May Lodge 2 YA42 To assure that everyone in the home is safe, obtain a hardwiring check without delay. May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 May Lodge DS0000065349.V352619.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!