Inspection on 22/07/05 for Smock Acre

This inspection was carried out on 22nd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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

Smock Acre 26/11/08

Smock Acre 18/12/06

Smock Acre 06/12/05

Smock Acre 08/02/05

Smock Acre 15/11/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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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 22/07/05 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 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 Stationary 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 H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Smock Acre Address Hollow Lane, Hoath, Canterbury, Kent, CT3 4LF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01227 860136 The Avenues Trust Limited Registered Care Home 3 Category(ies) of Care Home for Younger Adults (18-65) with a registration, with number Learning Disability - 3 of places Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Older People with a Learning Disability is restricted to one person whose date of birth is 28/09/1917 Date of last inspection 08/02/05 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 at the end of 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 half-acre garden on a steep gradient 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 home’s 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, Caroline Fleming, had recently handed in her notice. There was an acting manager in place, Fiona Cialis, who started in April 2005, initially on a temporary basis, now on a permanent basis subject to the successful completion of her probationary and registration processes. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was intended to introduce the new inspector to the staff and the current residents; to check progress against matters raised at the last inspection (February 2005); and to reach a preliminary view on the day-to day running of the home. There were three residents being accommodated by the home on the day of this inspection visit. The inspection process took just under six and a half hours, and involved meetings with the acting manager, the visiting Service Manager and two support workers. Meetings with the residents were not possible as none has verbal skills, sign language or Makaton. The inspection also involved an examination of records and the examination of the case file of the most recent admission, to track his care. All three residents’ bedrooms were inspected for compliance with the National Minimum Standards, and the inspector also checked all the communal areas. Interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? Some progress had been made with systematising personnel files, to enable anyone authorised to inspect them to judge compliance with the relevant regulations. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 6 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. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 1. Not all the documentary information necessary for potential residents to make an informed choice is available. 2. There is a systematic preadmission assessment process, which identifies needs, preferences and interests 3. This home accesses a range of social and healthcare professionals to ensure it maintains its capacity to meet the resident’s individual needs. 4. Prospective residents or their representatives have the opportunity to visit the home to assess the quality, facilities and suitability of the services it offers for themselves. The admission process also includes a flexible trial stay, before each admission is confirmed EVIDENCE: The homes latest editions of its Statement of Purpose, Service User Guide and placement contracts were not readily available, so the inspector was unable to judge whether they provided the representatives of the residents with all the information they needed before the residents moved into the home. None of the service users speaks, or uses any sign language or Makaton. This home has a block contract with the local Health Authority. An examination of the case file of the most recent admission confirmed that the Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 9 decision to place him in this home was based on a range of assessments. Some of these documents showed inaccuracies or outdated information, but were amended by the home through discussions with people who had known him before, including a member of the home’s own bank staff; by the home’s own assessment tools, and by checking his responses to ensure his identified needs could be met. He came to visit Smock Acre, had a couple of meals and stayed overnight, supported by his then key worker. The acting manager and support workers spoke enthusiastically about the positive changes they had seen in his social interactions, community presence and the way he was supported with his daily routines and activities. Records are set up to document access to a range of healthcare professionals as appropriate: epilepsy specialists, Occupational Therapy, audiologist, dentist, Speech and Language therapists as well as Primary Care Trust commissioners. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9, 10 6. The preadmission assessment and care planning processes cover a range of health and personal care needs, as well as some social care needs. Less clear, however, was the extent to which the residents are involved in these processes. 7. 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. 8. The current residents have a number of opportunities to influence their daily routines, and their responses are used to gauge their level of personal choice. 9. 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. 10. The arrangements for the storage and disclosure of confidential information is generally satisfactory, though some documents were not dated and it was not always clear who had produced them. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 11 EVIDENCE: There was a range of preadmission assessments on file, which were in the first instance drawn up by the NHS/PCT Trust, then updated (and in some cases corrected) by the home’s own. The home is in the process of adopting a Person Centred Planning approach to care planning but this transition process is by no means complete, so the inspection involved scanning a range of documents which will soon lose their currency, if they hadn’t already. It was not clear, from residents’ files, to what extent the residents are being actively engaged in the assessment and care planning process, or how the home establishes the resident’s own perspective and any emerging unmet needs. In the case file selected for closer examination, there was, for example an “Individual Service Specification”, which was clearly designed to address the health and social care needs of the residents, including issues like housing needs, finances, health, and self determination. It was written in the 1st person as if by the residents themselves – clearly this would not be possible, but the document was not signed or dated by the person or agency representing the resident in question. The Care / Support Plans which followed on covered a range of daily living routines, but the home does not appear to be summarising the care plans monthly so that progress and trends can’t be tracked by anyone authorised to inspect them. There was anecdotal information about the way staff interpret their likes and dislikes and their capacity to participate in personal care (one is, for example, able to offer his arms into sleeves) and daily routines, such as cooking or cleaning (e.g. holding food or household items while staff talk through the processes they are carrying out). This level of detail is not, however, being rigorously documented to enable anyone authorised to inspect the records to chart their progress. The care plans were usefully underpinned by risk assessments to cover the resident’s safety in the home, bus and community, but these were not dated or reviewed. Relatives are offered the opportunity to attend individual reviews but uptake is variable. The residents were observed being supported by staff in their own daily living routines. There was anecdotal information about the way the residents individually expressed their choices, satisfaction or dissatisfaction but this was not documented in any workable detail, and staff are reported to work with the residents in quite different ways. A more cohesive approach may be of benefit Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 12 to the residents. More detailed goals need setting, risk assessments require further development / application. The transition towards person centred planning requires completion. The home’s arrangements for keeping confidential information secure against unauthorized access was satisfactory. Cabinets and office facilities are all properly secured. Some documents were not, however, dated and it was not always clear who had produced them. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 17 12. There is limited choice over aspects of daily routines, subject to staff interpreting residents’ non verbal responses correctly. The current residents appear generally content with their lifestyles in this home, and the home has been able to match their expectations as interpreted by their representatives. 13. This home offers a range of activities inside and outside the home. Links with the community are invited and pursued, notwithstanding its isolated rural setting and staff support and enrich residents’ social opportunities. Access to activities is recorded. 17. The meals in this home offer choice and variety and are catering for the resident’s needs and preferences. Meals are enjoyed, unhurried and the setting is congenial. EVIDENCE: Abilities, activities and personal preferences are established as part of the preadmission assessment process, and confirmed by care plans and day-today planning thereon. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 14 These residents have high dependency needs and are non-verbal. Routine is quite important to the residents, but this can become obsessive. They are said to need the confidence to accept flexibility. There was anecdotal information about the way staff interpret their likes and dislikes and their capacity to participate in activities offered to them. This level of detail is not, however, being documented in sufficient detail to enable anyone authorised to inspect the records to chart their progress. The residents are taken to a range of sessions though they currently tend to observe and one is not yet ready to participate in some of them: exercise classes, relaxation and sensory experiences, gardening. Staff said they build up their activities by trial and error. Staff have noted that they can enjoy being in the sensory room and gardening sessions. Other sensory experiences available to the residents include TacPac sessions (involving a range of textures waved or patted on the skin), aromatherapy, hydrotherapy and music. Avenues Trust Ltd has its own day centre and uses community buildings for activities. 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 has its own dedicated adapted minibus and can access community resources for events not restricted to, or readily identifiable with, their disabilities such as pub lunches, a local fete and outings. Menus are planned a month in advance – there are winter and summer menus but these are applied flexibly. Staff make sure meals for two residents are chopped up into small enough pieces as they are unable to feed themselves. One can drink with his food. A speech and language therapist will be coming in to assess his scope for using a cup. The third resident is PEG fed separately elsewhere. The inspector joined the residents for lunch and observed how residents were supported with their meal. The dining area is a light spacious area, which provides a congenial setting for meals . Staff eat the same food and chatted light heartedly with them throughout. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 18, 19, 20. The current residents receive an appropriate level of support with their personal, emotional and healthcare needs. Personal care is offered in a way protect their privacy and dignity and promote their capacity for independence. 19, 20. The health needs of the current residents are well met with evidence of access to a range of healthcare services. EVIDENCE: The preadmission and care planning processes assess the extent to which each resident requires assistance with their own personal care, and their choice and control is actively promoted by staff as far as possible. All the bedrooms are single occupancy and there are enough toilet and personal care facilities (baths, showers, wash hand basins) to guarantee their availability and privacy. Staff are available on a 24 hour basis to assist residents. The care planning process routinely addresses a range of standard healthcare needs e.g. GP, optician etc. Records have been set up on file to document access to a range of other healthcare professionals as appropriate: epilepsy specialists; audiologist, dentist, OT, physiotherapy, dieticians. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 23. Residents are safeguarded against abuse, neglect and self-harm by a range of policies, staff training and staff commitment. EVIDENCE: These residents do not have access to independent advocacy services, and rely on families or staff to represent their interests. Avenues Trust Ltd has a Complaints procedure, which is given to residents’ families and is also available in audio and pictorial formats. There is no complaints register. These residents are non-verbal and do not use any sign language or Makaton. The challenge, therefore, 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 Home has a copy of the 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 their commitment to challenge and report any instances of abuse, should it occur. The rapport between staff and the current resident appeared appropriately familiar and respectful. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27, 28, 29, 30 24, 25, 28. The standard of the property is good. The furniture is a mix of domestic and specialist in style, and comfortable. Residents have a choice of communal areas, and there are homely touches throughout. 27. Each bedroom has a wash basin cubicle, and there are sufficient communal bath and WC facilities to guarantee their availability and privacy. 29. The home is wheelchair accessible and has ample useable floor space throughout. There is equipment and adaptations to meet the residents’ assessed needs. The garden areas are not, however, adapted for people with physical disabilities. 30. The home is well maintained, clean and free of offensive odours. EVIDENCE: The layout of this home is generally suitable for its registered purpose. All areas of the home were inspected and found to be homely, comfortable and clean. The furniture tends to be an appropriate mix, domestic in style and specialist / adapted. There were homely touches throughout. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 18 The front garden is reasonably flat but offers few discrete focal areas to draw attention to, or to sit in, and there are no paths across it, for use when the ground is wet. The rear garden is populated by fruit trees on a steep bank and is, therefore inaccessible to the residents. One resident is particularly susceptible to the sunshine, because of his medication and would require shaded areas. The site would benefit by private, sheltered areas and sensory gardens, ramps, paths and levelled areas, to facilitate access. The home has a “No Smoking” policy. Communal Areas The communal areas of this home are all open plan. There is a spacious lounge leading directly into the dining area and kitchen. All the windows offer pleasant views of the grounds and surrounding fields. The dining chairs are uniform in style, but this is appropriate for the staff or visitors who use them. The lounge furniture is more varied and includes a bean bag, a long bolster and mat for floor exercises. The residents all use their own comfywheelchairs. The kitchen is light, airy, clean and well maintained. No matters were raised for attention. Communal Bathrooms / WCs The communal WC and bathroom facilities are reasonably accessible to bedrooms and communal areas. There is a one Arjo Hi/Lo bath and a wheel-in shower (though this tends to be used by staff, not the residents). The flooring in the shower room was badly lime-scale stained, because it is said to be difficult to dry off this room. Light diffuser needed cleaning. No other matters were raised for attention. Bedrooms All the bedrooms are spacious and single occupancy. All the bedrooms were inspected and found to be well maintained. In terms of their furniture and fittings, they were generally compliant with the provisions of the National Minimum Standards, and each had its own range of sensory equipment. No matters were raised for attention. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36 31. Although some progress has been made with systematising personnel files, not all the documentation required by the regulations was in place, to clarify staff roles and responsibilities. 32. Staff feel they are suitably invested in, in terms of training opportunities and supervision, and gave a number of examples of the way they positively promoted the residents’ quality of life. 33. There was compliance with the staffing levels as described on the day of this inspection. Team working and support for the resident were identified as a key strength. 34, 36. The service users are safeguarded by recruitment processes, training and supervision EVIDENCE: Smock Acre has a staff establishment of 14 full time equivalent staff, which includes a House Manager; two senior Home Support Workers and 11 Support Workers. The acting manager described the following staffing arrangements. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 20 There are usually 3 staff on duty during the day (7.30-2.30/3pm; 2.30-10pm) and 2 at night (one on wake night duty, and one on sleep-in duty). Every day there is a senior on duty. The acting manager is on site three days a week, and there is an on-call rota system in her absence. There is no dedicated ancillary staff. Support staff do all the cooking and cleaning. There was compliance with these staffing levels as described on the day of this inspection, although staffing rotas were not analysed on this occasion. The manager was advised to include a legend on staffing rotas to explain any codes used on any rotas submitted for inspection; to detail her own on-site hours; and to record ancillary hours (cooking and cleaning) separately, where staff duties are split between direct care tasks and ancillary work so that anyone authorised to inspect the records can readily evaluate the staffing arrangements. Staffing rotas will be assessed at the announced inspection. Records and anecdotal information from staff confirmed a range of key training opportunities, such as food safety, fire safety, manual handling, First Aid, challenging behaviour, adult protection; as well as specialist training in issues such as challenging behaviour, epilepsy, sensory stimulation, stesolid, and care and management of gastronomy. One member of staff said “the training Avenues gives is really good. Statutory training is regularly updated, and training is available to fill any gaps”. The acting manager said she was scheduled to have training on facilitating Personal Centred Planning in September. The two staff who met with the inspector confirmed that they had regular formal supervision from their line manager, usually once every 1-2 months, though the frequency of this had lapsed with the registered manager leaving. The line management was said to be accessible and supportive. Although some progress has been made with systematising personnel files, not all the documentation required by the regulations is available in the home, to confirm anecdotal information from staff about the recruitment process, or to clarify staff roles and responsibilities. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 42 37, 38, 42. The Home is well managed, and actively supports the resident’s independence, health, safety and welfare. EVIDENCE: Since the last inspection, the registered manager, Caroline Fleming, had handed in her notice. The acting manager, Fiona Cialis, started in April 2005, initially on a temporary basis, and is now on permanent contract, subject to successfully completing her probationary period and registration application. The acting manager has had several years’ experience in the residential care sector, and has already established a good relationship with staff and the residents, and was reported to be very accessible and supportive. There are clear lines of accountability within the home and organisation. Some matters were raised for attention in respect of aspects of the record keeping (most notably, their dating, and authorship) but they were in the main judged in good order and maintained in the best interests of the resident. The Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 22 transition to Person Centred Planning should be of demonstrable benefit to the residents. Fire safety maintenance checks were selected at random for inspection and found to be up to date. Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 2 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 2 3 x x 3 Standard No 31 32 33 34 35 36 Score 2 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Smock Acre Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 24 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 YA1.1 Regulation 4& Schedule 1 Requirement The registered person must submit an up-to-date Statement of Purpose to the CSCI so that the inspector can judge its compliance with the National Minimum Standard and regulations. The registered person must advise whether this is available in other formats. The registered person must submit an up-to-date Service User Guide to the CSCI so that the inspector can judge its compliance with the National Minimum Standard and regulations. The registered person must advise whether this is available in other formats. The registered person must maintain copies of its Statement of Purpose, Service User Guide and placement contract on site so that prospective service users have all the information they need to make a decision to proceed with admissions The registered person must submit an up-to-date Placement Contract to the CSCI so that the inspector can judge its compliance with the National Timescale for action 30 09 05 2. YA1.5 5 30 09 05 3. YA1 4, 5 Immediate and ongoing 4. YA5 5(b)(c) 30 09 05 Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 25 5. YA27 23 6. YA34 7, 9, 19 & Schedules 2, 4(6) Minimum Standard and regulations. The registered person must advise whether this is available in other formats. Shower Room. The flooring in 31 1205 the shower room was badly limescale stained, because it is said to be difficult to dry off this room. This area requires attention. Action Plan to\be submitted That all documentation required 31 12 05 by this Regulation is in place for each member of staff (matter originaly raised in November 2004) 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 YA7 Good Practice Recommendations The home should complete the transition to Person Centred Planning demonstrate the active participation of the resident in this process. A more cohesive approach may be of benefit to the residents. More detailed goals need setting, risk assessments require further development / application. The home should look for ways to establishes the resident’s own perspective and any emerging unmet needs Documents should always be dated to demonstrate their currency, and it should always be clear who had produced them. 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. Shower Room. Light diffuser needed cleaning. 2. 3. 4. 5. YA7 YA7 YA10 YA22 6. 7. YA24 YA27 Smock Acre H56-H05 S23587 Smock Acre V238221 220705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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. 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