Inspection on 26/04/07 for Phoenix House

This inspection was carried out on 26th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Phoenix House 03/04/08

Phoenix House 23/08/06

Phoenix House 02/12/05

Phoenix House 13/06/05

Phoenix House 09/12/04

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

CARE HOME ADULTS 18-65 Phoenix House 1 The Drove Northbourne Kent Lead Inspector Joseph Harris Key Unannounced Inspection 26th April 2007 09:30 Phoenix House DS0000043898.V334983.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 Phoenix House DS0000043898.V334983.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. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Phoenix House Address 1 The Drove Northbourne Kent 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) 01304 379917 Phoenix Care Homes Ltd Mrs Karen Christine Moss Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2006 Brief Description of the Service: Phoenix House is a recently renovated home supporting up to 20 people with enduring mental health problems. The home is set in the small rural village of Northbourne, which is approximately 5 miles from the town of Deal. The village has a public house, post office and local shop. There is a bus service that links the village with local towns. The house is located within large grounds with ample parking spaces. The home benefits from a good range of communal spaces including a large conservatory, a games room, comfortable lounges and a substantial dining area. There is also a semi-independent flat with its own kitchen and lounge available for up to 4 service users. All bedrooms are single occupancy and have en suite facilities. The home has a vehicle to enable staff to support service users in the community and to access local amenities. The current fees for the service at the time of the visit range from £512.50 to £659.84 per week. Information on the Home services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection process culminated in a site visit to the home on April 26th 2007. The visit commenced at 9:30am and was completed at 4:30pm, therefore lasting for approximately 7 hours. During the course of the visit the inspector spoke to all of the service users about their experiences in the home, staff on duty and the current acting manager. In addition to this a tour of the premises was undertaken and a range of documentation and records were examined including those relating to service users, staff, health and safety issues and other records pertaining to the running of the home. 4 requirements and 9 recommendations have been made as a result of this inspection process. What the service does well: What has improved since the last inspection? The current manager has begun to develop a wider range of activities for service users. These include in-house groups such as arts and crafts sessions and establishing links with community groups/resources such as the Umbrella club, pathfinders and local community mental health centres. This is an area the manager stated that she wishes to continue to develop. Improvements are being made in respect of developing service user plans providing clear guidance for staff and assessing areas of need with an aim to support residents to a more independent lifestyle. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 6 Some improvements have been made following the previous inspection in respect of maintaining fire safety records and checks. The home has arranged a number of training courses including updates for mandatory training for all staff and mental health awareness courses. The manager has reviewed staffing arrangements to ensure that there is a designated driver on duty at all times throughout the day enabling the home vehicle to be used for service user’s needs. Improved systems for recording and monitoring healthcare input from professionals has been introduced. What they could do better: 4 requirements and 9 recommendations have been made as a result of this inspection process. It is acknowledged that there has been a time of change for the home with the previous registered manager deciding to retire and an acting manager currently in post. Requirements made at this inspection include the responsible individual appointing a manager to be put forward for registration with the Commission for Social Care Inspection. Issues surrounding the implementation of robust quality assurance and selfauditing measures need to be introduced and the review and updating of policies and procedures related to the home. A number of service safety certificates are also in need of renewal and updating including electrical wiring, PAT tests and a fire safety risk assessment. Among the 9 recommendations issues addressing updating the statement of purpose and contract for residents terms and conditions of residency were noted. To continue to develop an effective care planning system providing clear guidance for staff to meet needs. Review systems for recording controlled drug usage and to update complaints recording to demonstrate outcomes of any concerns or complaints raised. The home should also continue to work towards 50 of staff achieving an NVQ level 2 or above. An audit of staff personnel and recruitment files is advised ensuring all required information is in place for all staff. The responsible individual should review staffing levels to minimise times when staff are working alone in the home. The manager is also advised to seek advice from the environmental health department regarding service checks for oil powered and bottled gas appliance and for tests on the water supply. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 7 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. Phoenix House DS0000043898.V334983.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 Phoenix House DS0000043898.V334983.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 and 5. Quality in this outcome area is adequate. Prospective service users needs are suitably assessed and there is access to adequate information about the home, although areas of this could be further developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose in place, which contains suitable information regarding the home; it’s facilities and other aspects of the service. This document would benefit from review in the near future due to managerial changes. The Service Users Guide is in the process of being updated and reviewed. It is important that this guide becomes a central part of the admission and referral process and a copy is given to prospective service users. It was advised that it should be written in a manner that is easy to understand and to read. The guide should aim to provide all the information that prospective service users want to know and need to know. Refer to recommendation 1. The home has developed suitable pre-admission assessment processes, which are supported by CPA (Care Programme Approach) care plans, risk Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 10 assessments and other background information. The home completes a baseline assessment covering a range of needs, all of which contributes to the development of the individual care plans. The manager reported that when a referral is received she aims to visit the prospective service user as part of the assessment process before inviting them to visit the home. A contract covering the terms and conditions of residency is in place and a copy is retained on file for all service users. It is advised that this document is reviewed by the registered provider to ensure that all information is up to date, including Commission for Social Care Inspection details. Attention should also be given to the section addressing notification of any increase in fees and additional charges ensuring that systems are clear for providing advance warning of any fee increases and that a detailed list of additional charges is included. The registered manager should also consider the capacity of some service users when signing contracts and where there may be an issue of making an informed choice about all the information contained a third party representative should also be included. Refer to recommendation 2. Phoenix House DS0000043898.V334983.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 and 9. Quality in this outcome area is adequate. Service users individual needs are assessed and planned for. Residents are supported to make choices and decisions affecting their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home develops an individual plan of care for all service users following admission. Three care plans were examined during the course of the visit. All of the plans had a comprehensive assessment of needs and all of the identified needs contained guidelines and actions for staff. It was noted that some amendments could be made to the plans of care to make them easier to follow and less repetitive. The home has a system that uses generic headings covering a range of needs. This could be streamlined to focus in on specific areas of need for each service user and the home could further develop guidelines for staff to meet the assessed needs. Refer to recommendation 3. In Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 12 discussion with staff and residents it was evident that there was a good understanding of needs and how these should be met. Residents also confirmed that they are supported well by staff and that they receive positive and constructive support. Service users are supported to take decisions affecting their lives and provided with information and assistance as required. The home has developed links with the local mental health services and provides information about advocacy services and self-help groups. Residents are supported to manage their own finances and the home does not take an appointee role with any service users ensuring financial support is provided independently where required. Where limitations and restrictions need to be put into place, this is only done in conjunction with health and social care professionals and service users affected. There is a good risk management process in place, with clear individual risk assessments developed for each service user. The risk management plans take into account identified risks through the CPA process and any risks associated within the home. There are clear actions in place to minimise perceived risks. Risk assessments and individual care plans show evidence of regular review and updating. Phoenix House DS0000043898.V334983.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): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. Service users are enabled to have a lifestyle that suits their personal needs and can engage in appropriate activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager and staff team have begun to develop a greater range of local resource information and opportunities for service users providing support to attend outside activities and groups. This is an area that the manager has said she hopes to continue to expand. A number of service users have started to attend local groups such as Pathfinders, the Umbrella Club and mental health day centres. There are additional opportunities such as the Resource House and Shaw Trust that are also being investigated. The home has an occupational therapist who visits the home weekly and does an arts and crafts session with some residents who find it more difficult to go out independently. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 14 There are plans to increase these sessions to twice a week. Samples of some of the work were on display in the link room, which also has computers available for the residents to use. The home also has a range of leisure facilities available such as a snooker table, air hockey, basketball and a games console. Staff are available during the week to support service users in the community and the manager stated that she brings in extra staff as required, however the flexibility of staffing is an area that could be reviewed. The home is in a rural setting, in the small village of Northbourne, which has a post office and a public house. There is a reasonable bus link to the town of Deal, which is around 5 miles away. Deal has good bus links and a train station. Many of the staff live locally and have a good knowledge of the facilities available in the area. The manager has ensured that all service users will be able to vote in the local elections if they wish to do so. The home has a 7-seater vehicle to provide transport for service users. The manager ensures that a designated driver is on duty throughout each day. The home has a flexible visiting policy and encourages friends and relatives to maintain contact with residents of the home. One service user has recently been supported to re-establish links with a relative and the home is planning to provide accommodation when they come to visit due to the fact that they live some distance away. Restrictions on visiting are only imposed at the request of individual service users or in conjunction with the professional care team. Service users confirmed that the routines within the home are flexible and that they can choose, within appropriate boundaries, how to manage their time. Residents can choose when to get up and go to bed. Rotas are in place with regard to household chores and laundry. Staff were observed to interact well with residents and it was positive to note a collective respect between staff and service users. One resident is getting a kitten in the near future. There are rules with regard to smoking, alcohol and drugs. All residents spoken to stated that the food prepared in the home is of good quality and that there are a range of choices available at each mealtime. Residents are encouraged to assist with food preparation where appropriate including shopping and cooking. Residents are able to prepare snacks and drinks throughout the day and there is another small kitchen available for training if required. Special diets are catered for including requirements for cultural and religious diets as required. The home does not employ a cook so the task of cooking is undertaken by care staff. There is a large kitchen which was stocked with a range of good quality foods including fresh fruit and vegetables. Phoenix House DS0000043898.V334983.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 and 20. Quality in this outcome area is adequate. Service user’s personal and healthcare needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The main role of care staff in the home is to provide encouragement to service users to attend to their own personal care needs. Where structured support is required the methods for achieving this are included in the individual plan of care and there is a sensitive approach ensuring that individuals are assisted by someone of the same sex if required. There was also evidence that the manager is sensitive to the cultural requirements of service users in this respect. A number of residents spoken to commented that the staff are helpful and friendly. The home has a well established key worker system in place. The healthcare needs of service users are monitored, recorded and met. The manager has introduced new healthcare monitoring records, which identify what health input has been received and by whom. Outcomes from any Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 16 consultations and input are recorded and care plans amended as required. Service users have access to a general practitioner and mental health professionals, such as Community Psychiatric Nurses and Psychiatrists. Residents also attend community clinics to see chiropodists, dentists and opticians as required. Medication issues are generally well managed within the home, although a few minor issues were noted that could be further developed. The storage facilities in the home are suitable for the needs of the service and are maintained at an appropriate temperature. Administration records are kept up to date, although a number of gaps were noted on the administration charts, which is an issue the manager agreed to follow up. The home does have policies and procedures in place, but these should be further adapted and modified to reflect the individualised processes in the home rather than in the current generic form. Additionally the method for recording and monitoring controlled drug administration also needs to be updated introducing a bound book rather than the current loose-leaf system. Refer to recommendation 4. The medication room was well organised and medication stocks are regularly checked and monitored with records maintained of returned/destroyed medicines. None of the current service users are self-medicating, which is an area, following adequate assessment and liaison with professionals that could be further expanded. Phoenix House DS0000043898.V334983.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 and 23. Quality in this outcome area is adequate. Service users views are listened to and acted upon and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints process in place, which is on display within the home. The manager and staff aim to deal with any issues of concern on an informal level in the first instance, but should it be required there is a formal process stating timelines for responding to and dealing with any complaint. There is a complaints book in place, which had two relatively recent complaints recorded, however it did not give a summary of the actions taken to resolve these issues and was in a format that would not promote confidentiality. These issues were discussed with the manager who agreed to amend the home’s systems. Refer to recommendation 5. 1 complaint was raised through the Commission for Social Care Inspection and not directly with the home. This issue has been satisfactorily resolved following liaison with the home manager and complainant. The manager of the home demonstrated a good understanding of issues surrounding protection against abuse and adult protection. The majority of staff have undertaken Adult protection training and a further update for all staff is planned in July 2007. There are policies and procedures in place Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 18 relating to issues of abuse, however these are in a generic form and are brief and out of date having been last updated in 2004. Many developments have occurred within the field of adult protection and abuse awareness and these documents need to reflect this and incorporate local reporting, recording and monitoring processes. Refer to requirement 1. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is good. Service users live in a homely, comfortable and conducive environment that is maintained to a good standard of cleanliness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Phoenix House is set in the rural village of Northbourne approximately 5 miles from the seaside town of Deal, which benefits from a good range of facilities and public transport links. There is a bus service that connects Northbourne to Deal and the home also has access to a 7-seater vehicle. The home is surrounded by extensive gardens and has car parking to the front of the building. It is a large house with 20 single bedrooms with en-suite facilities. There is a good range of communal spaces including 2 main lounges, a conservatory, a designated smoking room and a large dining room. There is also a link room which is used for activities and has a computer available for Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 20 service users. The home also benefits from an integrated 4-bedded supported living unit with it’s own kitchen and living room. There is a large main kitchen and adequate storage facilities and a separate laundry which is well appointed with two washing machines and a tumble drier. Residents are encouraged to personalise their bedrooms as they wish and confirmed that they have adequate furniture and fittings within their rooms to meet their needs. The home is maintained in a good state of repair and is well furnished and decorated. Processes for controlling the spread of infection and universal precautions are in place. All hazardous substances are appropriately stored and it was reported that the home complies with water supply and fitting regulations and comply with the requirements of the environmental health and fire departments. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 21 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, 33, 34 and 35. Quality in this outcome area is adequate. Service users are supported by an appropriately recruited, competent and effective staff team employed in adequate numbers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff spoken to during the site visit demonstrated a good awareness of the needs of service users and principles of good practice. A number of the staff have worked in the home since it opened and have clearly developed good working relationships with the service users. This was confirmed by residents who stated that they feel well supported by staff. Currently 3 of the care staff have achieved an NVQ level 2 or above and one other staff member has just commence an NVQ in April 2007. At the present time less than 50 of the care staff have achieved an NVQ in care and this is a target that the home should continue to strive towards. Refer to recommendation 6. 3 staff personnel files were examined, which contained the majority of information required although some omissions were noted. The manager should conduct an audit of all staff files to ensure that all required information Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 22 is in place including CRB and POVA checks, proof of identity, at least two written references and completed application forms including a full employment history. The home has had two application forms in use, one of which does not adequately provide space for potential employees to give a clear employment history including dates previous employment started and finished. Refer to recommendation 7. There are adequate numbers of staff on duty at all times in accordance with department of health guidance. The home operates with 2 care staff throughout the day and 1 waking and 1 sleep-in staff member at night. In addition to this the manager is on duty from 9am-4.30pm from Mon-Fri. It was reported that extra staff can be brought into the home when required. Although the staffing levels are within acceptable limits it is strongly advised that these are reviewed with reference to the needs of service users and potential risk factors and in conjunction with the fact that the home does not employ any ancillary staff such as cooks or cleaners. There are times, especially at weekends, when staff are effectively lone working due to residents being escorted into the community or staff undertaking non-care working roles. The home should also review the competency of sleep-in staff who do not normally work in the home at other times. Refer to recommendation 8. The home has continued to provide training for staff in mandatory and additional courses. A series of updates and refresher courses have been booked for staff for the coming months covering a number of mandatory courses including fire safety training and manual handling. New staff work through an induction programme, which comprehensively covers a range of topics regarding general principles of care, supporting independence and equality issues as well as service specific topics. A discussion was had with the manager regarding the introduction of a competency based induction programme linked to the Skills for Care Common Induction Standards. Additional training courses have been organised including a mental health awareness course. It is advised that senior staff at least continue to develop this area of their practice and knowledge with a view to participating in more in depth courses addressing mental health issues. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 23 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, 40 and 42. Quality in this outcome area is adequate. The home is well managed, but the manager has not yet been registered and the responsible individual needs to develop quality assurance processes. The health and safety of service users is promoted although fire safety issues need to be monitored more effectively. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current acting manager, who is yet to be registered with the Commission for Social Care Inspection has worked in the home for a number of years as Deputy Manager and has many previous years experience in the caring profession having taken on managerial roles in the past. She is currently Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 24 working towards achieving her NVQ level 4/Registered Manager’s award. In discussion it was evident that she has clear visions and values about the development of the home and demonstrated a desire to continue to improve the service and expand her own knowledge. The responsible individual does need to make a permanent managerial appointment and put forward the proposed manager for registration with the Commission. Refer to requirement 2. The responsible individual has introduced some quality assurance processes, but these now need to be further developed ensuring that an accountable managerial structure is in place. Services will now have to demonstrate robust quality assurance and self-monitoring processes to a greater a degree. Aspects of this include regular auditing of records, documentation and maintaining development plans. The home also needs to develop satisfaction questionnaires including those for service users, staff, visitors and professionals. The manager stated that questionnaires had been completed for service users some time ago. When responses are received these should be incorporated within an annual report providing feedback about responses and what actions the home is going to take to address any issues that arise. The report should also include areas of the development for the coming year and a precise of achievements and events over the preceding year. The home does complete regulation 26 monthly monitoring visits, but this is another area that would benefit from further review and development. Refer to requirement 3. The home has a policy and procedure file in place, which contains documents relating to all the key aspects of the running of the home and business. However the policies and procedures are mainly generic and relate to generalised care establishments. Whilst this is satisfactory with regard to majority of issues some attention should be given to update these documents where the process differs within the home such as with regard to medication and adult protection policies. Additionally the policies in place show no evidence of review since 2004 and should be reviewed and updated on an annual basis. Refer to requirement 1. There are a number of health and safety issues within the home that require attention. The majority of records were reasonable well maintained and up to date and staff have received mandatory training or have refresher courses booked for the near future. There are adequate processes to ensure safe working practices and good risk management structures in place. However some documentation and service checks were out of date including the NICIEC electrical wiring certificate, Portable Appliance Tests and the fire safety risk assessment. Refer to requirement 4. It also advised that the home contacts the environmental health department in relation to required safety checks on the oil powered and bottled gas appliances and for Legionella. Refer to recommendation 9. Improvements have been made in respect of fire safety monitoring, but the home is advised to ensure that these checks are recorded clearly to avoid confusion or omissions. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 2 33 X 34 2 35 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 2 X 2 X Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 26 Yes 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 YA40 YA20 YA23 Regulation 13(2)(6) Requirement To ensure that all policies and procedures are specific to the home and are reviewed annually with particular reference to adult protection and medication policies amongst others. To appoint a permanent manager and put the individual forward for registration with the Commission for Social Care Inspection. The Registered Provider should strengthen aspects of the internal quality assurance system used in the home. In particular, the following points should be actioned 1. appropriate methods should be introduced to enable all of the service users to comment meaningfully on the adequacy of their home 2.an Annual Quality Report should be prepared which summarises the service users’ opinions and which gives the Registered Provider’s response to any suggested improvements 3. the Quality Report should be fed back to the service users so that they know what is going to DS0000043898.V334983.R01.S.doc Timescale for action 01/07/07 2 YA37 8, 9 01/07/07 3 YA39 12 01/07/07 Phoenix House Version 5.2 Page 27 4 YA42 13(4), 23 (4)(5) be done to implement their suggestions. (Previous requirement. Timescale of 01/02/07 not met.) To ensure all service certificates are up to date including NICEIC electrical wiring and PAT tests. To ensure that the fire safety risk assessment is reviewed and updated annually. 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA1 YA5 Good Practice Recommendations To review the information contained within the statement of purpose and service user guide ensuring the latter is written in an easily understandable and informative style. The registered provider should consider updating and reviewing the information contained within the service users contract, ensuring fee increases are notified to purchasers and additional charges are included. To review the current care planning structure working towards a more streamlined approach and developing more informative action plans. To update medication policies and procedures introducing clear processes individualised to the home. To introduce the use of a bound book format for recording controlled drug administration and stock. To update the recording of complaints ensuring that outcomes of concerns raised are clearly recorded and monitored and by introducing a complaints record that ensures confidentiality. To continue to work towards 50 of staff achieving an NVQ level 2 or above. To conduct an audit of staff files ensuring all required information is included and that any gaps in employment histories are fully accounted for. To review staffing levels in the home taking into account service user needs and minimising times of lone working in the home. To ensure the competency of sleep-in staff who do not DS0000043898.V334983.R01.S.doc Version 5.2 Page 28 3 4 YA6 YA20 5 YA21 6 7 8 YA32 YA34 YA33 Phoenix House 9 YA42 work in the home at other times. To seek advice from the EHO regarding service checks on the oil powered and bottled gas appliances and in respect of Legionella and water supply. Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 29 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 Phoenix House DS0000043898.V334983.R01.S.doc Version 5.2 Page 30 - 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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