Inspection on 26/09/06 for St Leonards Place

This inspection was carried out on 26th September 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Leonards Place 04/10/05

St Leonards Place 25/04/05

St Leonards Place 08/02/05

St Leonards Place 01/11/04

St Leonards Place 02/12/03

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Thorndene

Insight - Eastchurch

Southfields

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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 St Leonards Place 96 Maidstone Road Chatham Kent ME4 6DG Lead Inspector Marion Weller Key announced Inspection 26th September 2006 01:00 St Leonards Place DS0000029027.V313070.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 St Leonards Place DS0000029027.V313070.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. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Leonards Place Address 96 Maidstone Road Chatham Kent ME4 6DG 01634 405120 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) St Leonards Place Ltd Mr Russell Peter Martin Care Home 3 Category(ies) of Learning disability (3) registration, with number of places St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: St Leonard’s Place is a specialist residential service, offering 24-hour care and individual support to three service users with learning disabilities and challenging behaviour. The home also offers a day care facility to one client. This service was not inspected. St Leonard’s Place is a large Victorian house providing 3 purpose built flats for individual living arranged over three floors. There are stairs and steps leading to all floors. The home is situated in a residential area less than a mile from Chatham town centre and is located on a main bus route and within walking distance of shops and a Post Office. There is parking to the front of the building and an attractive back garden. The home has its own transport. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by Marion Weller, Regulatory Inspector who was in St Leonard’s Place from 1:00 pm until 6:20 pm. Due to the specialist nature of the service and the lifestyle of the resident group, this inspection necessitated a short period of notice being given to manager of the inspector’s arrival. While visiting the home the inspector spoke with two of the residents, the manager and some staff. Some judgements about the quality of life within the home were taken from observations and conversation. Some records and documents were looked at. In addition, a tour of the home and parts of the grounds were seen. The individual flats and communal areas within the home were found to be clean, welcoming and homely and from entering, people were observed to be busy and positively engaged. Sufficient staffing levels were noted to support each individual resident. Comments received from residents included: “On a score of 1-10, this place is a 10!” “Happy, much better than other places I’ve stayed in” The manager and staff were very welcoming and gave their full co-operation throughout the inspection. Current fees range from £1500 to £2900 per week. Charges vary according to individual assessed need. What the service does well: Staff had a comprehensive understanding of residents needs and individuals felt well supported. The home is largely concerned with maximising independence and affording the responsibilities that come along with that ethos. Residents spoke highly of the manager and the staff and their ability to exercise freedom and choice, both in their leisure activities and in daily routines. Staff were seen to be motivated in providing a high standard of care and an excellent rapport was observed between residents and staff. St Leonards Place DS0000029027.V313070.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. St Leonards Place DS0000029027.V313070.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 St Leonards Place DS0000029027.V313070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12345 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. People who use this service have sufficient information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means peoples diverse needs are identified and planned before they move to the home and they have a contract, which clearly tells them about the service, they will receive. Individuals can be confident the home can meet their needs. EVIDENCE: Although the current service users have been resident in the home some time, the manager clearly understood the importance of having sufficient information to help prospective residents or their representatives make a firm decision about moving into the home. The home has a statement of purpose and a service users guide that is specific to the specialist service they offer and the resident group they care for. Both documents have been regularly reviewed. Residents had copies of the home’s information documents in their flats. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 9 The home’s current information documentation meets the needs of the majority of residents in the home. However, the manager is aware that good practice demands that the home’s information documents should be available in other formats to meet the capacity of all current and any future prospective resident and is currently considering updating information in this way. Residents were provided with a statement of terms and conditions when moving into the home. Evidence was seen of the home’s contracts in residents care plans, which were specific and detailed. The manager explained the home’s pre admission process and how it takes place over a six-week period. The process includes trial visits for the prospective resident to the home and can also involve staff exchanges to ensure everyone has the opportunity to get to know each other and to see if the home can fully meet their needs. In such an intimate and very specialist service ensuring that the mix of residents is correct is vital. The manager was keen to emphasise the importance of getting this right for the benefit of all residents in the home. St Leonards Place DS0000029027.V313070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 8 9 10 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents can be confident that their individual needs and choices are well supported by the home’s care planning documentation. Residents can be confident that they will be consulted and participate fully in all aspects of life inside and outside the home and are supported to take risks as part of their independent lifestyle. Residents benefit from information about them being handled appropriately and their right to privacy is maintained. EVIDENCE: Detailed individual care plans were seen for residents. They included risk assessments where necessary. Action was seen to have been taken to minimise identified risks and hazards. Residents were aware of advice given about the promotion of their personal safety. Elements of the care plan included daily living plans, support plans, treatment plans and identification of St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 11 individual’s health needs. Reviews of care plans are regularly undertaken by the home and records were being maintained of these events. Residents’ daily records were detailed and signed by staff. Residents have access to all care planning documentation held about them and can contribute to its formulation and review. Residents were seen to make decisions about their lives with assistance as required. Each resident has the benefit of an ‘ethical committee’ which involves interested parties involved with their care such as parents, social workers, health professionals, key worker and the manager. These individuals meet to take any joint decisions where necessary. The resident is fully included and supported to take part in the process. Residents evidenced in conversation that they live in an environment where they are constantly encouraged, enabled and supported to consider and make decisions about their own lives and to be as independent as possible. Support and advice from staff was being offered when requested. Staff were seen working alongside residents in the daily routines of the home. The service is person centred in its approach and residents participate fully in the running of the home, and in particular the organisation of their own flats. There is an ethos in the home of fully supporting residents’ rights and in equal measure individuals are also supported to understand the responsibilities that goes along with this ethos. The home has a policy on confidentiality which was available to staff and residents. A resident spoke of a situation where they felt their right to privacy had been compromised. The manager and the resident explained how this had been dealt with to their satisfaction. Records were stored in a secure area when not in use and access only granted to appropriate people. St Leonards Place DS0000029027.V313070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 14 15 16 17 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. The potential for a resident’s personal development are good with ample opportunities to maintain and develop independent living skills. The home facilitates meaningful and appropriate leisure activities, which enable residents to enjoy a varied and full lifestyle. Links with the community are encouraged which support and enrich an individuals social and educational opportunities. EVIDENCE: Residents described how they were encouraged to pursue interests and hobbies both individually and on occasions collectively. A number of activities were discussed such as fishing, visits to the cinema, leisure centres, clubs/pubs, shopping and eating out. Residents undertook activities based on individual risk assessment. One resident regularly used the local bus into town. The home also has its own transport. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 13 Family links and friendships are promoted and maintained in the home. One resident spoke of having their parent(s) to stay in their flat and making visits away from the home. The manager explained that residents are free to have friends to visit when they wish and may have overnight guests as well. Each resident has their own flat and are therefore able to receive visitors in private. One resident is employed on a training scheme 4 days a week. Another resident was not employed but undertook a range of activities in the home and in the local community. It was evident that residents had control over the activities they did or did not participate in. Staff offered support and guidance if it was in the resident’s best interests, but the choice ultimately was theirs. Residents’ flats are their own responsibility. Each has a list of chores that cover cleaning, cooking etc. One resident spoke about purchasing and cooking their own food. Staff offer guidance to ensure that residents plan nutritious meals. Staff do not routinely intrude on residents privacy in their flats unless specific tasks are identified that the individual requires support with. These elements are assessed and the level of staff support and guidance is agreed with the resident and recorded in their individual plan of care. It was clear that residents are encouraged to learn, maintain and develop practical life skills to their full potential and capacity in the home. St Leonards Place DS0000029027.V313070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 21 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents can be confident that their personal and health care needs will be met in full. Residents are protected by the home’s medication policies and procedures and residents benefit from a risk based approach to the self-administration of medication. They would further benefit from all staff having received accredited training in the safe administration of medication. EVIDENCE: The personal and health needs of residents are well met with evidence of good multi disciplinary working taking place on a consistent basis. The home promotes and maintains residents health by facilitating and supporting residents with medical appointments as necessary. This includes visits to Opticians, Chiropodists and other health professionals. On the day of the site visit a resident had attended a hospital appointment accompanied by the manager. Notes of the outcome of the consultation had been accurately recorded in the resident’s records and were available for the resident to read and reflect upon. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 15 All residents are registered with a GP of their choice. Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents in their care. Attention is given to ensuring an individuals privacy and dignity is maintained during personal care and it was clear that staff are sensitive to the individuals changing needs. There was clear evidence of medication reviews taking place in care plans and a risk assessment approach to residents’ self-administration of medication. Residents are very involved in organising their own medication regimes. i.e. taking repeat prescription requests to the GP to maintain optimum stock levels. One resident self-administers their own insulin via an insulin ‘pen’ device. District nurses have taught staff and the resident how to do this safely. Records of ongoing competency in this area must be maintained by the home. The manager stated the intention to ensure this happens. For residents who have the capacity staff dispense medication into individual self-administration systems. The exercise does not adhere strictly to good practice guidance but it is part of the home’s policy and procedures for medication administration. It was stated that particular attention is paid to accuracy in this practice. The manager supports the practice as it encourages independence for the resident. Residents spoken with were also supportive of the practice as it gives them some control and freedom in regard to their medication regimes. The process had been risk assessed as part of the residents’ treatment plan and is further supported by the ethics committee for the individual. Staff sign the medication sheets when they witness a resident taking medication and to keep control over the amount of medication supplied. Medication sheets seen were comprehensively maintained. There was still no picture of the resident on the three medication administration sheets viewed and no record of the individuals known allergies. This should be addressed. Some staff had received medication administration training. Due to the nature of this very singular and individual service and its strong emphasis on the promotion of residents’ independence and supported risk taking, it is recommended that all staff that deal with residents’ medication should have received comprehensive accredited medication training. The manager spoke of the illness, death or dying of residents. The home supported a previous resident until they were admitted to hospital five days before their death some years ago. This was a sensitively managed. The manager said that the home would always offer individuals full support if they were ill or had a terminal diagnosis for as long as the home could meet their individual medical needs. The manager spoke of personally supporting staff and the resident’s family members during that time. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 16 St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents are protected from potential abuse and have access to a clear complaints procedure which they fully understand and know how to use. They further benefit from having their views and concerns listened to and acted upon without delay. EVIDENCE: The home has a clear complaints procedure that meets the demands of regulation. The residents and staff understood the complaints procedure and were clear about whom they would approach if they had any concerns. As with other information documentation the home maintains they would be advised to consider producing this in a format for any current or future resident that lack capacity. The Home had received no complaints since the last inspection and thus has no written records or records of outcomes of complaints and concerns. Neither has the home made any notifications to the CSCI since it was registered. One resident spoke of a concern regarding a staff member that had been dealt with speedily and resolved by the manager to the satisfaction of all involved. This event would have been recorded in the individual’s personal records. The manager said this is a small and fairly intimate service and their work involves meeting regularly with other professionals, parents and advocates. Issues of concern, once raised, are picked up and dealt with very quickly in other forums. Residents were clear that they felt safe and were aware that the service views their protection and safety as a priority. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 18 The manager has a good understanding of the protection of vulnerable adults process and whistle blowing procedures. The home has adopted the revised Kent and Medway Adult Protection Policy and has made progress in assuring that all staff receive training. The manager spoke of his intent to ensure that more courses in the area of protection are to be arranged for staff not yet trained. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 30 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents benefit from living in a safe, well maintained, clean and homely environment in which good standards of décor are maintained. EVIDENCE: The home provides a physical environment and layout that is appropriate to the specific needs of the three residents who live there. The accommodation is divided into three self contained flats each comprising of a bedroom, bathroom, kitchen and sitting room with its own front door and entrance. Each flat was decorated and furnished to a high standard and had been personalised according to each individual residents taste. Residents are free to entertain and to accommodate family and friends in the privacy of their own flats. The home had high standards of cleanliness and no odours were present throughout. Rooms were comfortable, kept tidy and were well lit. Residents confirmed that there was always plenty of hot water for their use. The home ensured that water temperatures in the home were tested regularly and checks for Legionella had been undertaken. Thermostatic Mixer Valves have been St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 20 fitted to water outlets in resident areas. Ventilation and room temperatures are maintained under the individual occupants own control in each flat. Laundry facilities are sited within each of the flats kitchens. This is appropriate to the style of individual service offered, machines are domestic in nature. Hand washing facilities are prominently sited with disposable towels available. The home has an infection control policy and procedures are in place for the disposal of clinical waste. Personal protective clothing is available if required St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents benefit from being cared for by a staff team who are well supported and supervised. The home continues to train its staff to ensure residents’ needs are met at all times. Residents are protected from potential abuse by the home’s robust recruitment procedures EVIDENCE: St Leonard’s Place has a small dedicated staff team of 9 individuals including the manager. Staff work a 24-hour roster. The home does not use agency staff and therefore residents benefit from an experienced staff team who know them well and understand the home’s way of working. Staff files inspected indicated residents were being protected through the use of robust staff recruitment procedures. Staff were only employed after necessary references and checks had been obtained and were found by the home to be satisfactory. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 22 The home has a full ‘in-house’ induction-training programme and the manager ensures new staff also receive foundation training within six months of their appointment. Staff files evidenced job descriptions and person specifications for the staff members respective role. Staff spoken with were aware of their role and how it supported the goals set out in the residents plan of care. There were clear lines of accountability in the home, which staff were aware of and understood. Formal staff supervision takes place regularly, usually bi-monthly. Supervision records were seen which also identified the staff members training needs. The manager keeps the records stored securely when not in use. The home’s training records were seen and the manager discussed the home’s current staff training profile. 75 of staff had completed NVQ training at either level 2 or 3 and the manager holds a level 4. The manager has made progress in meeting the requirements made at the last inspection in relation to obtaining training for all staff in Adult Protection and Challenging Behaviour. The manager has robust plans to ensure that this identified training need is fully met by March 2007. As mentioned elsewhere in the report, accredited medication administration training needs to be added to the home’s training plans. Staff are aware of their own knowledge and skill limitations and through observation it was clear that they appropriately involve the manager if they are concerned or require more specific expertise or direction. Records show low rates of staff turnover and sick leave and a high level of moral was evidenced during the visit. Residents spoke highly of the staff and appeared very comfortable them. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 40 41 42 43 Quality in this outcome is good. This judgement has been made using available evidence including a site visit to this service. Residents benefit from having a manager that is qualified, competent and well supported by his staff and who provides clear leadership that aims to consistently improve the service and the outcomes for residents. Residents’ finances were protected and their welfare promoted through regular environmental safety checks. EVIDENCE: The manager has completed a NVQ Level 4 in Care and Management and was able to demonstrate that he had the experience and knowledge to ensure the best and most appropriate support and care for the resident group. The manager is also currently looking at ways to develop and update his own practice and knowledge base meeting skills for care specifications. St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 24 The residents benefit from the management approach in the home. The manager creates an open and inclusive atmosphere and it was clear that residents and staff find him approachable, friendly and supportive. The home’s lines of accountability are clear and were well evidenced. The home takes quality assurance seriously and regularly reviews aspects of its performance through review and consultation. The manager surveys residents and their representatives about the quality of service the home provides them with on a monthly basis. Responses inform the home’s future practice. It was discussed that it would be advisable to further collate the information into a format that all stakeholders in the service can see, including the CSCI. The information could be fed into an annual review of the service. The home has a full range of policies and procedures, which have been reviewed to ensure they comply with recent legislation and good practice guidelines. The manager was advised to ensure that each of the home’s policies, procedures, codes of practice and records are signed by the registered manager and are dated, monitored and show a clear review and amendment date for inspection purposes and to evidence the home’s obvious good practice. Records required by regulation for the protection of residents and for the effective and efficient running of the home are maintained and up to date. The manager ensures as far as is possible the health, safety and welfare of the residents within a risk assessment framework. Residents’ financial interests were protected with either themselves or representatives dealing with their finances. The manager does not act as appointee for handling residents financial affairs. Neither residents nor their representatives expressed any concerns about the home’s management of monies. The home evidenced safe storage for hazardous substances and held COSHH data sheets for advisory purposes. Water temperatures are controlled by the fitting of Thermostatic Mixer valves. Risk assessments for the property have been undertaken. The manager said the home was financially viable and had access to professional business and financial advice. The company holds all the necessary insurance cover to enable it to fulfil any loss or legal liabilities. St Leonards Place DS0000029027.V313070.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 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 2 ENVIRONMENT Standard No Score 24 4 25 3 26 3 27 3 28 X 29 X 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 4 3 3 3 3 3 St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 23 A(1) Requirement To ensure Adult Protection training is completed for all staff. (Previous timescale of 30/03/06 partly met) To ensure Challenging Behaviour training is up to date for all staff. (Previous timescale of 30/03/06 partly met) Timescale for action 30/03/07 2. YA35 36 (2) 30/03/07 St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 27 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 YA1 Good Practice Recommendations It is a good practice recommendation to make the service user guide and the home’s other information documentation such as the complaints procedure into a pictorial format with easy reading, so it is suitable for current or future residents who lack capacity. It is strongly recommended that: 1. All staff dealing with residents’ medication receives comprehensive accredited training in the safe handling and administration of medication. 2. The home’s medication policy and procedures for the handling of medication complies with the requirements of the Medicines Acts 1968 and the guidelines from the Royal Pharmaceutical Society of Great Britain publication - “The Administration and Control of Medicines in Care Home’s” It is strongly recommended that the home consider collating the information gained from quality assurance exercises into a format that all stakeholders in the service can see, including the CSCI. The information can be fed into an annual review of the service. It is recommended that each of the home’s policies, procedures, codes of practice and records are signed by the registered manager and are dated, monitored and show a clear review and amendment date for inspection purposes and to evidence good practice. It is recommended that the home revisit the Regulation 37 guidance for the scope and type of notification that should be sent to the CSCI to ensure the protection of residents. 2 YA20 3 YA39 4 YA40 5 YA42 YA23 St Leonards Place DS0000029027.V313070.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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