Inspection on 03/04/08 for Phoenix House

This inspection was carried out on 3rd April 2008.

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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Phoenix House 26/04/07

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 CT14 0LN Lead Inspector Mark Hemmings Unannounced Inspection 3rd April 2008 09:00 Phoenix House DS0000043898.V361177.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.V361177.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.V361177.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Phoenix House Address 1 The Drove Northbourne Kent CT14 0LN 01304 379917 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) Phoenix Care Homes Ltd Post Vacant Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2007 Brief Description of the Service: Phoenix House (the Service) is registered to provide accommodation and personal care for 20 people who have difficulties with managing their mental health. The premises are a detached property that has quite a large garden to the rear. The accommodation is provided on the ground and first floor. All of the people who live in the Service have their own bedroom. All of the bedrooms have a private bathroom with a wash hand basin and toilet. The Service is set in the small rural village of Northbourne. This is approximately five 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 Service has its own people carrier vehicle. This means that support workers can assist people to be out and about. The Registered Provider is a private limited company. It also runs another residential care service in the area. The fee for each person’s residence in Phoenix House is £669.69 per week. The fee includes the provision of accommodation, personal care, catering, laundry and use of the people carrier. It does not include items such as the purchase of toiletries and other services such as consultations with the hairstylist. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this Service is One (1) Star. This means that the people who use this Service experience adequate quality outcomes. The commission since 1 April 2006, has developed the way it undertakes its inspection of care services. This inspection of the Service was an unannounced “Key Inspection”. The Inspector arrived at the Service at 09.00 and was in the Service for about five hours. It was a thorough look at how well the Service is doing. It took into account detailed information provided by the Registered Provider. Further, it considered any information that the commission has received about the Service since the last inspection. There are seven Requirements at the end of this Report. What the service does well: The people who live in the Service say that there is a relaxed atmosphere in their home. They say that they receive the assistance they need and that members of staff are courteous and respectful. People are assisted to promote their health including obtaining medical assistance. People say that they receive good quality meals. More than one half of the support workers hold a relevant National Vocational Qualification. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 6 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. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 7 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.V361177.R01.S.doc Version 5.2 Page 8 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): Standards 1, 2 and 5. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People are told about the facilities and support they will receive. There are gaps in the information that is collected about the assistance needed by people who move into the Service. EVIDENCE: People who might want to move in are invited to visit the Service so that they can get a first hand feeling of what the place is like. They can also get information from the Service Users’ Guide. This is a brochure that outlines the main things available in the Service. There is also a document called the Statement of Purpose. This gives a more detailed account than does the Guide. For example, it explains how the Service is staffed. The Registered Provider ensures that a copy of our most recent Inspection Report is available. The Manager completes an assessment of each prospective person’s needs for assistance. This is done before a decision is made about whether or not the Service can meet the person’s needs. The assessment is completed in consultation with the person concerned. As appropriate, members of their Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 9 family are involved. We looked at the assessment completed for two recent admissions. In relation to Person A there was information about his/her mental health diagnosis and about the need to assist him/her manage their use of alcohol. In relation to Person B, there was no clear information about his/her mental health diagnosis. Also, there was no information about the need to respond to occasions when the person becomes troubled with odd thoughts. There is a Requirement in relation to this Standard at the end of this Report. Each person or their representative receives a written account of the rights and of the responsibilities they accept when they move in. There is information about the fees to be paid and about what they include. Phoenix House DS0000043898.V361177.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): Standards 6, 7 and 9. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. The provision of personal support is well planned. Money held on behalf of people is managed properly. People are helped to not take unnecessary risks. EVIDENCE: The people who live in the Service say that the support workers offer them all the assistance they need. There is a written individual plan of care for each person. These are important documents. This is because they form one of the means by which people can say what help they need. Also, the plans are a source of information for staff. This then helps them to provide support in a consistent manner. Five sets of these plans were examined. They contained information about a number of relevant things. For example in relation to Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 11 Person A there was information about his/her family relationships. In relation to Person C, there was information about how support workers should respond to his/her troubled thoughts. In relation to Person D, there was information about how to recognise when he/she is becoming unwell with their mental health. In relation to Person E there was information about how the person’s mood can change a lot each day. Support Workers A and B were aware of this information. The Manager holds some people’s personal spending monies in order to help them budget. The records relating to Person F and to Person G were examined. They gave a clear account of the various transactions involved. Two people were asked about the arrangement. They said that they are quite happy with the help they receive to manage their money. People are helped not to take unnecessary risks. For example, they are asked to think about whether or they might need help when they go out into the village or further afield. For those who smoke, they are asked to do this in the smokers lounge rather than in their bedrooms where there could be a fire risk. Phoenix House DS0000043898.V361177.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): Standards 12, 13, 14, 15, 16 and 17. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. The calendar of occupational opportunities is not well organised. People do a range of social things. People are helped to keep in touch with family and friends. Good quality meals are served, but there are gaps in the catering records. EVIDENCE: People are free to do occupational things that interest them. For example, one person goes to a local resource centre where he/she can take part in a range of occupational activities. There is an activities coordinator. She calls twice a week to help people work on a variety of craft projects. However, there is no clear account of who is doing what. Also, there is no broad plan so that people can have a rough idea of what their week will look like. The Manager is going Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 13 to speak with each person so that she can double check that everyone is being offered the activities that they want. She is also going to prepare a broad plan for each person, together with a record of who is doing what. These developments are going to be completed by 1 August 2008. People say that the pace of daily life in the Service is relaxed and unhurried. While they have considerable choice about how to spend their day, there are broad expectations about some of the things they will do. For example, they are expected to adopt reasonable personal practices such as not going to bed too late. People are helped to be out and about. We asked about the circumstances of Person I who is not able to go out on their own. This was done to see how often he/she leaves the Service in practice. The records show that he/she left the Service on five occasions between 4 March 2008 and the date of the inspection. Another person who does not go out alone is Person E. She said, “I can go out as I like. I go out with staff for a walk and in the bus (people carrier)”. We looked at the number of times she had left the Service recently. The records showed that he/she left the Service on five occasions between 6 March and the date of the inspection. The events included visits to his/her family and trips out with staff. People are helped to keep in touch with members of their families, if this is necessary and if it is their wish. Family members and friends are welcome to call to the Service at any reasonable time. The Manager in consultation with the person concerned, keeps in touch with family members so that they know how things are going. We spoke with a relative of Person H. She said that the Manager does indeed keep in touch with her and that she appreciates the way this enables her to be involved in things. There are various social activities. These include trips out to places of interest and things such as going bowling. Person H has just returned from a holiday that he/she wanted to have in the west county. He/she was accompanied by a support worker. He/she said, “ I had a brilliant time and I want to do the same thing next year”. We spoke with the person’s relative about this matter. She said that she is very pleased about the way in which the Manager consulted with her and then made the holiday possible. People say that they receive good quality meals and that they have enough to eat. They consider meal times to be a relaxed and pleasant experience. The Manager said that there is a choice of dish available at each meal time. Four people were asked about this. Two of them did not seem to be clear about there being a choice. The record of the food actually served was examined. There were gaps. For example on 1 April 2008, the food served for breakfast and lunch was not recorded. On 2 April 2008 the main part of the lunch was not recorded. On neither day was there any evidence that there had been a choice of meal at lunchtime. There is a Requirement in relation to this matter at the end of this Report. Phoenix House DS0000043898.V361177.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): Standards 18, 19 and 20. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. People are helped to support themselves. This includes using health care services. There is a shortfall in one aspect of the administration of medication. EVIDENCE: Support workers are courteous in their manner and they respect each person’s individuality. People say that they can rely upon support workers to be there when they are needed and to be approachable. Person A summarised the general mood when he/she said, “the staff here are really good and helpful. They’re easy to talk to and they help me to get on with things that I know I need to do but probably wouldn’t do without reminding”. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 15 People are assisted to maintain their health. Support workers are alert to the need to identify occasions when someone is becoming unwell. This is so that medical assistance can be sought promptly. Since the last inspection, Person H has been assisted to have an operation and to have follow-up physiotherapy. Other people have been helped to attend medical appointments and to have things like dental checkups. People are free to manage their own medicines when this is appropriate. None of them have chosen to do this at present. The Manager checks medicines when they are received in the Service to make sure that they are the right ones. Once in the Service, medicines are stored securely. There is a procedure that is followed when medicines are given out. This is done to double check that the right medicine is given to the right person and the right time. Three sets of records relating to medicines dispensed by support workers were reviewed. There were no gaps and the records tallied with the medicines that were left in store. Person F has a medicine that can be used as and when it is needed. There were no written guidelines about when it should be given. Also, there had not been any real discussion with the person concerned to obtain their agreement to the use of the medicine. There is a Requirement in relation to these matters at the end of this Report. Phoenix House DS0000043898.V361177.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): Standards 22 and 23. People who use the Service experience good outcomes. This judgement has been made using available evidence including a visit to the Service. There is an error in the information contained in the complaints procedure. The wellbeing of the people who live in the Service is safeguarded. EVIDENCE: There is a written complaints procedure. This explains how people can go about raising a concern. It is usually best for people to try to resolve concerns informally with the Registered Provider. However, they do have the right to approach us without first going to the Registered Provider. The procedure does not explain this option. The Manager said that this will be put right by 1 May 2008. Since the last inspection, the Registered Provider has looked into two complaints. One was from a relative of Person E. It concerned a number of aspects of the care provided. We looked at the records of how this matter had been handled. We saw that each point had been considered and that the Registered Provider had met with the relative to explain the situation. The other complaint was made by Person H. This concerned an incident that occurred between himself/herself and Support Worker C. We looked at the records of how the matter was investigated and resolved. The conclusion Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 17 reached was that the support worker had not been courteous when responding to Person H. There was evidence that the support worker had been advised about this aspect of his/her conduct. Person H told us that he/she is satisfied with the way in which his/her concerns had been managed. There is a written statement of the Registered Provider’s commitment to promote the wellbeing of the people who live in the Service. The support workers are aware of how to go about safeguarding in practice the interests of the people who live in the Service. For example, Support Worker A said that this includes being alert to indirect signs that someone is not being treated well. He/she said that he/she would become concerned if someone became withdrawn or agitated without apparent reason. People say that they feel safe living in Phoenix House. Phoenix House DS0000043898.V361177.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): Standards 24, 29 and 30. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. People live in a generally comfortable setting that promotes their independence. There are gaps in some fire safety records. The kitchen is clean. The laundry is well equipped. EVIDENCE: Most areas of the accommodation are decorated and furnished to a normal homely standard. Some of the toilets and bathrooms are rather bare and uninviting. The carpet in bedroom 4 has rather a musty smell. The room is not in use at the moment. The carpet will need to be cleaned again or replaced before the room is next occupied. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 19 The accommodation was comfortably warm when we were there and people said that this is always the case. The premises are fitted with an automated fire detection system. This provides a high level of fire safety protection. The Registered Provider has prepared a fire risk assessment. This has been done to double check that there are no problems with how the system works in practice. The assessment shows that a number of improvements are considered to be necessary. When we looked at the records we could not tell whether or not the improvements had been done. The Registered Provider is going to make sure that any matters that are outstanding are completed by 1 August 2008. The kitchen is clean and well organised. The local Department of Environmental Health has not asked for any improvements to be made. Some people need extra help in the bathroom because they have difficulties with their mobility. Support workers know what assistance they have to provide. There is suitable equipment in place to enable them to do this safely and reliably. This includes a walk-in shower and a special rise and fall bath. The laundry is equipped with a washing machine and dryer. People are encouraged to do their own laundry, but in practice most rely upon support workers to organise this for them. Each person has a sufficient supply of clean and presentable clothes from which to choose. There are new regulations that have been introduced to ensure that used water does not leak back into the main pipe-work. The Registered Provider is going to check with the local water supply company to make sure that it complies with these provisions. This will be done by 1 June 2008. Phoenix House DS0000043898.V361177.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): Standards 32, 33, 34 and 35. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. The Service is adequately staffed. There is a gap in one set of the security checks. There are some shortfalls in the ongoing training arrangements. EVIDENCE: There are two support workers on duty during from early in the morning until later in the evening. On six days there is a third support worker who is on duty from 9.00am to 5.00pm. At night time, there are two support workers present. On three days there is a housekeeper. There is no cook. This means that support workers need to spend some of their time in the kitchen. There is an on-call system. This means that someone senior can be contacted for advice out of office hours. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 21 The Registered Provider completes a number of security checks for new support workers. This is done to ensure that they are trustworthy people. The records relating to Support Worker B were examined and were satisfactory. However, in relation to Support Worker D there was no information at all about his/her previous employment history. This meant that we could not be sure that the necessary references had been obtained. There is a Requirement in relation to this matter at the end of this Report. There is a total of 10 support workers employed in the Service. To date, six of them have obtained a National Vocational Award in health and social care. This qualification is designed to develop their ability to provide a high quality residential care service. New support workers receive introductory training before they work without direct supervision. The Manager organises this using a model that we regard to be good practice. We looked at the records in relation to Support Worker D and we noted how he/she had completed the necessary tuition. We also looked at the records for Support Worker B and noted how he/she was progressing through his/her induction in an orderly manner. After the introductory training, support workers they are provided with ongoing training in subjects that the Registered Provider considers to be compulsory. We looked at how this is organised. We noted that there were some gaps. For example, in relation to first aid Support Worker G had not done any organised additional training. In relation to the protection of vulnerable adults, Support Workers E and F had not done the training. In relation to food hygiene, the Manager and Support Workers A, B, C, D, E, G and H had not completed the course. The Manager is going to be more explicit in future when deciding which members of staff need to have what training. This will be done by her completing an assessment of the skills and knowledge each of the support workers already possesses. She is going to do this using a framework that we think is very useful. This exercise will be completed by 1 September 2008. We spoke with Support Workers A and B about aspects of their work. They have a good knowledge of what they are doing. This includes an awareness of the nature of mental health diagnoses. It also includes how to help people in an effective way when they are becoming anxious or concerned about something. Phoenix House DS0000043898.V361177.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): Standards 37, 39, 40 and 42. People who use the Service experience adequate outcomes. This judgement has been made using available evidence including a visit to the Service. The Manager does not hold the relevant qualifications. The quality assurance system does not collect enough information. There are relevant written policies and procedures. There are gaps in some of the health and safety arrangements. EVIDENCE: The Registered Provider is not in day to day control of the Service. This means that it has to employ a Registered Manager to run the Service. To be registered in this role, the Manager has to have particular qualifications in both Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 23 health and personal care and also in management. The qualifications are important because they focus upon how good management practice can contribute to positive outcomes for the people who live in the Service. The Manager is currently studying for one the qualifications and hopes to have it by the end of the year. The Registered Provider needs to support her to complete the qualification. Also, it needs to apply to us to consider her for registration as soon as the qualification is awarded. Various things are done to support good team-work. These include handover meetings at the beginning and end of each shift. Also, there are staff meetings. Several things are done to consult with people about how well the Service is running. These include informal discussions and the completion of more organised questionnaires. We looked at these questionnaires. There were seven completed by people who live in the Service, five from relatives and three from care managers (social workers). We noted that people generally are very happy with how things are going. There are shortfalls in the arrangement. Members of staff are not included. Also, there is no organised system to tell contributors what is going to be done to respond to any suggested improvements. The Registered Provider is going to address these omissions. This will be done in time for the results to be notified to the Commission in 2009, when the Registered Provider submits its next Annual Quality Assurance Assessment. There are written policies and procedures. Most of these have been prepared to assist staff to carry out their work. They deal with subjects such as health and safety. For example, the proper management of substances such as bleaches. The documents are easy to read. Support Worker B said that he/she had been asked to read them as part of his/her introductory training. Regular checks are completed to ensure that the Service’s fire safety equipment remains in good working order. These include a weekly test of the fire alarm bells and periodic more detailed checks completed by a contractor. There are unannounced fire drills. However, the records do not clearly show that each member of staff has been assessed as knowing how to operate reliably the Service’s fire safety procedure. There is a Requirement in relation to this matter at the end of this Report. When the electrical installation was last inspected there were three improvements noted for urgent attention and 18 items that were of lesser importance. We looked at the records to see if the matters had been addressed, but there was no clear statement. There is a Requirement in relation to this matter at the end of this Report. The Service has bottled gas. There were no records to show that the gas installation had been serviced in the past year and certified as being safe-worthy. There is a Requirement in relation to this matter at the end of this Report. Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 24 There have not been any significant accidents or other unwelcome events in the Service since the last Key Inspection. The Manager checks the premises and the accommodation to ensure that there are no hazards that might cause someone to have an accident. She said that says that no such problems have been identified. We looked at the maintenance records and they showed that repairs are completed promptly. Phoenix House DS0000043898.V361177.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 3 2 X 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 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 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 3 X 2 X Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) (a) Requirement The registered person shall not provide accommodation to a service user at the care home unless so far as it shall have been practicable to do so the needs of the service user have been assessed by a suitably qualified or suitably trained person in that, the Registered Provider must in relation to prospective admissions gather all of the information needed to support the delivery of care. The registered person shall maintain in the care home records of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition and otherwise and of any special diets prepared for individual service users in that, the Registered Provider must ensure that a suitable record is kept of all main dishes provided at breakfast, lunch time and tea time. Timescale for action 01/05/08 2. YA17 17 (2) Schedule 4 (13) 01/05/08 Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 27 3. YA20 13 (2) The registered person shall make 01/05/08 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home in that the Registered Provider must in relation to Person F ensure that there is a clear account of when the discretionary medicine should be given and that the person has consented to this arrangement. The registered person shall not employ a person to work at a care home unless … he has obtained in respect to that person the information and documents specified in paragraphs 1-9 of Schedule 2 – a full employment history together with a satisfactory written explanation of any gaps in employment in that, the Registered Provider must in relation to Support Worker D obtain the necessary information. The registered person shall after consultation with the fire and rescue authority ensure by means of fire drills and practices that the persons working at the care home and so far as practicable service users, are aware of the procedure to be followed in the case of fire including the procedure for saving life in that, the Registered Provider must ensure that all members of staff at least once in every period of six months are validated as being competent to operate the fire safety procedure. The registered person shall not DS0000043898.V361177.R01.S.doc 4. YA34 19 (1) (b) Schedule 2 (6) 01/05/08 5. YA42 23 (4) (e) 01/06/08 6. YA42 23 (2) (c) 01/07/08 Page 28 Phoenix House Version 5.2 use premises for the purposes of a care home unless the equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order in that, the Registered Provider must submit to us written confirmation that all items of work noted to have been outstanding in relation to the electrical wiring installation have been addressed. 7. YA42 23 (2) (c) The registered person shall not use premises for the purposes of a care home unless the equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order in that, the Registered Provider must submit to us written confirmation that all gas installations and gas fired appliances have been inspected and certified as being safeworthy by a competent person. 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Phoenix House DS0000043898.V361177.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone 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.V361177.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. 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