Inspection on 18/12/06 for Smock Acre

This inspection was carried out on 18th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Smock Acre 26/11/08

Smock Acre 06/12/05

Smock Acre 22/07/05

Smock Acre 08/02/05

Smock Acre 15/11/04

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 Smock Acre Hollow Lane Hoath Canterbury Kent CT3 4LF Lead Inspector Jenny McGookin Unannounced Inspection 18th December 2006 10:00 Smock Acre DS0000023587.V312513.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 Smock Acre DS0000023587.V312513.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. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smock Acre Address Hollow Lane Hoath Canterbury Kent CT3 4LF 01227 860136 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) The Avenues Trust Limited Fiona Cialis Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Older People with a Learning Disability is restricted to one person whose Date of Birth is 28/09/1917 6th December 2005 Date of last inspection Brief Description of the Service: Smock Acre is a care home, first registered in 1999 to provide accommodation and personal care to 3 adults with a learning disability, who have additional physical needs. Currently, there are 3 service users in residence. The registered provider is the Avenues Trust Limited, which has been operating since 1993 and is now a major provider of residential support services in South East England. Maintenance of the building is by Kelsey Housing Association. The home is a large, spacious bungalow along a farm road outside the rural village of Hoath, surrounded by fields. It is approximately 8 miles from the city of Canterbury and 6 miles from the seaside town of Herne Bay. There is a halfacre garden at the rear, and a large flat garden at the front. The home is not on any direct bus route, and the farm road does not have footpaths or street lighting. Residents rely on the homes own adapted minibus to access the community. There is a drive on either side of the site with ample parking spaces in each case. The home itself is fully wheelchair accessible. The gardens are not. The registered manager is Fiona Cialis, who started in April 2005, initially on a temporary basis. The current fees for the service at the time of the visit are £2208.90 per week. Information on the home’s services and the CSCI reports for prospective residents should be detailed in the Statement of Purpose and Resident Guide. The e-mail address for this home is: smock.acre@theavenuestrust.co.uk Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit, which was intended to inform this year’s key inspection process; to check progress on matters raised for attention at the last inspection (December 2005), given all the timeframes had run their course; and to review findings in respect of the day-to day running of the home. The inspection process took seven hours, and involved meeting with the visiting service manager, the senior support worker in charge, a support worker, two bank support workers and a visiting reflexologist. The registered manager was not on duty. The inspection also involved a complete tour of the premises and the examination of a range of records. One resident’s files were selected for care tracking. Conversations with the residents were not possible because of their level of disability, but interactions between staff and the residents were observed during the day. What the service does well: The layout of this home is generally suitable for its registered purpose, and convenient for visitors as long as they have cars. The property is being maintained to a very satisfactory standard. The home continues to make good use of the regulatory processes. Only one matter was raised for consideration. The health and personal care needs of the current residents are generally well addressed, and there continues to be good evidence of holistic care planning. There is input from a range of healthcare professionals. The residents are supported to understand what choices are available to them. Staff actively try to improve the quality of lives of the residents, each of whom has very high support needs and had lead very controlled, institutionalised lives before their admission to Smock Acre. The home also provides opportunities to access the community and to be involved in day-to-day routines such as cooking and cleaning, as far as they are able. Staff continues to confirm there is a systematic approach to recruitment, regular supervision, training and a good level of management support. And staff show a commitment to challenge and report poor practice, should it ever occur. Overall, there continues to be a high level of compliance with the National Minimum Standards throughout the inspection process. Smock Acre DS0000023587.V312513.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. Smock Acre DS0000023587.V312513.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 Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 Although there have been no new admissions since February 2005, policies are in place to ensure this is managed appropriately. Each placement is subject to terms and conditions governing the rights and responsibilities of both parties. EVIDENCE: Two of the current residents had no choice about their transfer from previous placements, as these decisions were led by the Primary Care Trust, which has a block contract with Avenues Trust Ltd. And both of these residents were admitted in February 1999 i.e. before the emergence of the Care Standards Act 2000 and the National Minimum Standards. The third resident was admitted in February 2005, and his admission process is reported on in July 2005. This placement did involve an element of choice. Avenues has a policy on admissions which describes a careful step-by-step process, based on multi disciplinary assessments and meetings, and which is inclusive of the resident’s responses (and their representatives) at every stage. This process includes overnight stays, joining in with activities and a trial stay of three months, which can be extended. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 9 The home’s Statement of Purpose and Service User Guide need to be read in conjunction to obtain full compliance with all the elements of this standard. But, this being the case, people representing the interests of prospective residents would have access to all the information they need to make an informed choice. Each placement is confirmed by a contract, which is intended to be read in conjunction with a Licence Agreement (governing the landlord / tenant relationship), a “Terms and Conditions of Residence” document and the home’s Statement of Purpose. When read in conjunction, they do obtain full compliance with the elements of this standard. Work is being done to produce a much simplified picture / symbol assisted version of the Statement of Purpose, Service User Guide and contract. This is judged a very promising development. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 6,7,8,9,10 Individuals are involved in decisions about their lives, and play as active a role in planning the care and support they receive, as they are able. EVIDENCE: The preadmission assessment and care planning processes cover a range of health and personal care needs, as well as social care needs. The home has made good progress with the introduction of a “Person Centred Planning” approach to care planning. These plans are written in the 1st person to ensure the writer keeps the residents’ responses and interests central. Families and friends are welcomed, and their involvement in the care planning process is encouraged. And this process is usefully ratified by Avenue Trust’s own annual auditing process within Avenues Trust, which has been focussing on Person Centred Planning this year. The home was judged to have obtained excellent progress. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 11 The current residents were observed being supported in the daily routines, and observed interactions between staff and the residents were appropriately familiar and respectful during this inspection. The residents have more opportunities to influence their daily routines, and “Opportunities Sessions” are used to gauge their level of personal choice when presented with modest choices e.g. with tastes or colours. Planning meetings (involving other professionals and relatives) are being used to further extend their experiences. This is judged potentially exemplary practice. There are risk assessments to cover the residents as individuals, their activities and their environment (inside and outside the home), to maximise their capacity to be independent and community access (see section on “lifestyle” for more details). The arrangements for the storage and disclosure of confidential information is satisfactory. The home has lockable facilities, and a unique tagging system to ensure access to hard copy information is properly accounted for, and computer records are password protected. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 11,12,13,14,15,16,17 People who use services are supported to make choices about their life style, and to develop their life skills. Social, educational, cultural and recreational activities meet individuals’ expectations. EVIDENCE: Abilities, activities and personal preferences are properly established as part of the preadmission process, and confirmed or amended by care plans and dayto-day planning thereon. These residents have high dependency needs and are non-verbal. Routine is quite important to them, and this can sometimes become obsessive. But staff have to be able to interpret their non-verbal responses correctly in order to Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 13 encourage them to develop the confidence to accept flexibility. One notable achievement has been overcoming one resident’s dislike about being outside in the dark, which increases his scope for off site activities. Avenues Trust has its own day services, which operate out of community buildings and settings. The residents have access to a range of therapeutic sessions (exercise, relaxation, sensory sessions, hydro-therapy) and staff (from the home and day services) discreetly observe their responses with a view to building up their positive participation from passive observation. The home is in an isolated rural setting, and there is no path along the access road, which would make its use by pedestrians dangerous. But since the last inspection the residents have been able to benefit by better access to the garden (a path and patio area has been created), and home has acquired a replacement minibus, which is even better adapted to take wheelchairs than the previous one– so that residents can be supported to access community resources not restricted to, or even readily identifiable with, their disabilities such as pub lunches, cinema and theatre visits, library. The home has built up a good relationship with a local vicar, who visits the home regularly and has helped with the grounds maintenance, and residents have, in turn, been attending church events. And staff have even been able to undertake more ambitious experiences such as train trips to London events to good effect. Menus are planned a month in advance, and there are winter and summer menus, but these are applied flexibly. The registered manager is committed to healthy eating and has increased the proportion of meals cooked from fresh primary ingredients over the past year. None of the residents can feed themselves without support, and texture can be an issue for them, but staff make sure it is cut up into small enough pieces for them. One resident is PEG fed. One meal was sampled as part of this inspection visit, and judged well prepared and presented. Residents were observed being supported with the meal and appeared to enjoy the experience. The dining area is light and spacious, and provides a congenial setting. As has been reported at the previous two inspections, staff eat the same food – which is judged a sound quality assurance tool. Residents appear to enjoy their lifestyle, but there are other quality assurance tools in prospect - Avenues Trust will be focussing on active lifestyles and nutrition next year. This is judged potentially exemplary practice. Smock Acre DS0000023587.V312513.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 This judgement has been made using available evidence including a visit to this service. 18,19,20 The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The preadmission and care planning processes properly assess the extent to which each resident requires assistance with their personal care, and their choice and control is actively promoted by staff as far as possible. The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician, dentist, district nurse etc. Records have been set up to document access to other healthcare professionals as appropriate: epilepsy specialists, speech therapist, Occupational Therapist, Physiotherapist, dietician (e.g. re PEG feeding). Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 15 This inspection visit coincided with a visit by a reflexologist, who has been working with one resident to good effect. The reflexologist feels that he has been able to obtain better balanced bodily functions for the resident in question. All the bedrooms are single occupancy, so that there is scope for residents to meet with visitors, including healthcare professionals in the privacy of their rooms. And during the course of this inspection visit, one of the residents was accorded this privacy with a visiting reflexologist. The medication storage, administration and recording arrangements were judged satisfactory. There were no apparent gaps or anomalies in the medication administration records seen. Two staff undertake each medication round and the balance is being routinely checked on each occasion. Nine staff are reported to be trained to administer medication and ten are reported to have up-to-date First Aid certificates. Medication training used to feature in staff foundation training but has been introduced at staff induction stage. Avenues Trust has a comprehensive policy on ageing, illness and death, which requires care plans to be redrafted to meet the elements of the National Minimum Standards. These will be written in the 1st person and will identify the kind of music to be played, words to be spoken and where the resident would want to be buried etc. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 22,23 People who use the service are supported to express their concerns, and there is a complaints procedure, as required. Residents are protected from abuse, and have their rights protected. EVIDENCE: Avenues Trust has policies on complaints and whistle blowing, which are judged comprehensive. The complaints also has a picture-assisted version and a CD version to make it more accessible, though this is more likely to benefit residents at other homes in the group. No complaints have been recorded in the home’s complaints register. These residents would not have the ability to comprehend the concepts of making a complaint as such – staff would need to interpret any negative responses. A lot of work has been done to draw up communication passports. The challenge continues to be to find ways of translating expressions of dissatisfaction into recordable events, so that anyone authorised to inspect the register can evaluate the extent to which their responses are listened to and acted upon. These residents are on a waiting list for Canterbury advocacy services, but there has been no input to date. They rely on families or staff (and to some extent the services of a local vicar) to represent their interests. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 17 The home has a copy of the Kent and Medway Multi-Disciplinary Adult Protection policy, to ensure a timely and co-ordinated approach, should an adult protection issue arise. In discussions with staff, they invariably confirmed feedback from previous inspections, in respect of their commitment to challenge and report any instances of abuse, should they occur. The rapport between staff and the residents appeared appropriately familiar and respectful. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 24, 25, 26, 27, 28, 29, 30 The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The standard of the property is good. The furniture is a mix of domestic and specialist in style (e.g. comfy wheelchairs), and comfortable. Residents have a choice of communal areas, and there are homely touches throughout. The home is wheelchair accessible and has ample useable floor space throughout. There is equipment and adaptation to meet the residents’ assessed needs. The garden areas are only partially adapted for people with physical disabilities, but since the last inspection work has been done to create a path and patio area to improve access. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 19 Each resident has a bedroom, which has furniture and fittings generally suitable to meet their needs, though the design of one bed head is not as conducive to his moving and handling as the other residents’ beds, and should be reviewed. Each room has been personalised and provided with sensory equipment. Each bedroom has a washbasin and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. The home is well maintained, clean and odour free. All maintenance records seen were up to date and systematically organised. Both matters raised for attention at the last inspection had been attended to. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 32,33, 34,35,36 Staff in the home are skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. But Avenues Trust needs to ensure it obtains and maintains compliance with the requisite level of NVQ accreditation to meet the National Minimum Standard. EVIDENCE: This home operates with a minimum of two care staff day and night, and three when off site activities are planned. The acting manager is on site five days a week and there is an on-call system in her absence. There are no dedicated ancillary staff – support staff do all the cooking and cleaning and are to be commended on the high standards maintained in each case. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 21 Meetings with staff confirmed records and feedback in previous inspections, in respect of Avenue Trust’s recruitment process and the range of key training opportunities available to staff, to keep the residents safe. There have been changes in the staff group and the staff team is now more gender-balanced. Pre-inspection information indicates that only 30 of the current staff team have NVQ level 2 accreditation or above, but this level is anticipated to rise to something like 44 over the next year. Staff confirmed that they had regular formal supervision, usually once every 68 weeks, and line management is said to be accessible and supportive. Smock Acre DS0000023587.V312513.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): Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Mrs Fiona Cialis’ application to be the registered manager of this home was ratified by the CSCI at the beginning of September 2006, which means she has been able to demonstrate she has the relevant qualifications and experience for this role. Feedback continues to confirm that obtained at previous inspections, that she has established a good relationship with staff and the residents, and is reported to be very accessible and supportive. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 23 There are clear lines of accountability within the home and organisation. The service manager’s monthly inspection visits (Reg 20) continue to be judged exemplary in their scope and the conspicuous links they make with the National Minimum Standards. The organisation as a whole maintains a proactive overview and can also demonstrate that it places its stakeholders at the centre of a range of quality assurance initiatives. This year there was an audit of the home’s PersonCentred Planning processes, which found the home had made excellent progress, and more audits (of nutrition and activities) planned for next year. There was also a mail-shot to relatives and visiting professionals, which bore useful comparison with the Commission’s own tools, and which produced very positive feedback on the services. Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 4 3 3 3 X Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 25 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 YA35 Regulation 18 Requirement Avenues Trust needs to ensure it obtains and maintains compliance with the requisite level of NVQ accreditation in the staff group, to meet the National Minimum Standard Timescale for action 31/12/06 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 YA22 Good Practice Recommendations Complaints Register. The challenge will be to translate residents expression of dissatisfaction into recordable events, so that anyone authorised to inspect the records can evaluate the extent to which their responses are listened to and acted on. The site would benefit by private, sheltered areas and sensory gardens, ramps, paths and levelled areas, to facilitate access. Consideration should be given to the moving and handling difficulties presented by one resident’s bed. 2. YA24 3. YA26 Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 26 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 Smock Acre DS0000023587.V312513.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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