Inspection on 20/11/07 for St Marks

This inspection was carried out on 20th November 2007.

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

Other inspections for this house

St Marks 17/01/07

St Marks 09/02/06

St Marks 03/08/05

St Marks 24/11/04

St Marks 17/06/04

St Marks 26/02/04

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Southfields

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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 Marks 23 Collier Road Hastings East Sussex TN34 3JR Lead Inspector Caroline Johnson Unannounced Inspection 20th November 2007 09:30a St Marks DS0000021225.V350793.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 Marks DS0000021225.V350793.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 Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marks Address 23 Collier Road Hastings East Sussex TN34 3JR 01424 200854 01424 200854 23collierroad@tiscali.co.uk 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) A S D Unique Services Limited Post Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is six Residents will be over the age of eighteen on admission and below the age of sixty five Residents will on admission be diagnosed as suffering from autism Date of last inspection 17th January 2007 Brief Description of the Service: St Marks provides long term care for people over the age of eighteen who have been diagnosed as having an autistic spectrum disorder. This can include people with Aspergers syndrome. Each residents needs in respect of education and leisure time are assessed and a programme of activities arranged. The property is situated in a residential area on the West Hill of Hastings and is within walking distance of Hastings. St Marks is a three-storey building. There is no lift so residents need to be able to use the stairs. St Marks is one of four homes owned by the proprietors Mr and Mrs Kennard. The fees for the service range from £1,080 to £1,180 each week. Additional charges are made for hairdressing, toiletries, magazines and papers. Inspection reports are made available via the home upon request. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process a site visit was carried out on 20 November 2007. The visit lasted from 09.30am until 18.35pm. During the visit there were opportunities to spend time with two of the residents and to meet briefly with two other residents. Time was spent with the manager of the home and also with two care staff. One of the residents provided a tour of the communal areas, bathrooms, his bedroom and the laundry. He also assisted with the monitoring of the hot water temperatures. Two care plans were examined in detail. A wide range of other documentation was examined including records held in relation to complaints, menus, staff training, quality assurance, house meeting minutes and staff meeting minutes. A full tour of the building was not undertaken but all bathrooms and communal areas were seen. Following the inspection of the home contact was made with the relatives of two of the residents. Comments received were very positive and included ‘ the home are very supportive to our son and to us, my son says that staff are kind’, we are very content with the service our son receives, ‘we have never had any serious issues and the staff bend over backwards to accommodate us’, ‘all the staff are excellent and we know that if we ask for anything it will be carried out’, ‘we wouldn’t find better anywhere else’. A visit was also made to the head office on 30 November to look at staff recruitment records. What the service does well: What has improved since the last inspection? Improvements have been made to the way in which the residents’ house meetings are run. Emphasis has been placed on ensuring that residents are making more informed choices and decisions about their home, how it is to be decorated, the food they eat and how they spend their day. A staff member spoken with stated that since taking up her position one of the main St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 6 achievements the manager has made has been ‘to empower the residents to make more informed choices and decisions’. Changes have been made to the system for care planning to ensure that only relevant information is included and is more easily accessible. Risk assessments are more specific in detailing the level of the risk and the action to be taken by staff. It is the manager’s intention to continue to develop this area further. The downstairs toilet has been refurbished and is now a shower room and toilet. The laundry area has also been refurbished and includes a new washing machine. In addition there is a new fridge/freezer in this area. The lighting in this room has also been replaced. Residents chose the colour scheme for this room and there is now a picture gallery in this area displaying pictures chosen by the residents. Improvements have been made to the medication system and record keeping is now much more detailed. Recruitment procedures have been revised and the administration side of this is now carried out at the head office. Significant progress has also been made in encouraging residents to have a healthier diet by introducing more varied fresh fruit and vegetables. 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. St Marks DS0000021225.V350793.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 Marks DS0000021225.V350793.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 adequate. This judgement has been made using available evidence including a visit to this service. It is essential that the home have a detailed statement of purpose in place detailing the type of service it is providing. EVIDENCE: A requirement was made at the last inspection of the home that the statement of purpose be updated to include the changes to the management of the home. The document could not be located at the time of inspection. Work to upgrade the service user guide has been ongoing for over a year now but little progress has been made. A staff member spoken with stated that they have spoken with residents to seek their views on what should be included in the guide. One resident wanted a photo of the back of the house to be included. Further work is to be undertaken to ensure that residents actively take part in the process. The residents’ charter has been updated. This includes information written by the majority of the residents about various activities and events that they were involved in throughout the year. Photos are also included. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 9 There have been no new admissions to the home since the last inspection. St Marks DS0000021225.V350793.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. Significant progress has been made in updating care plans to ensure that they include relevant information about the needs of the residents and how they are to be met. The ongoing work to encourage residents to make more informed choices and decisions is to be commended. EVIDENCE: Two care plans were examined. Staff advised that progress has been made in trimming down care plans to ensure that only relevant information is included and to ensure that the documents are therefore working documents. At annual reviews goals are identified for individual residents and each resident signs agreement. Residents are not currently given a copy of their goals. Care plans are very comprehensive and include detailed assessments including an autism specific assessment, management guidelines and primary care guidelines. Records are kept showing how individual needs are met. Whilst St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 11 one resident has a very detailed plan of care in place it is noted that this resident is well for a period of time and then appears to experience a period of time where he is far less motivated, withdrawn and isolated. The care plan mainly refers to the time when he is more motivated. Staff are working hard to try to encourage motivation and have sought specialist advice to assist in this area. However, the care plan does not fully reflect the extensive work undertaken by staff to support this resident. The format for carrying out risk assessments has changed and the majority of those seen included specific information about the perceived risks and the action to be taken by staff to prevent accidents/incidents occurring. The manager advised that this is an ongoing piece of work that will continue to be developed. House meetings are held weekly. Each of the residents takes it in turn to chair the meeting. House issues are discussed to ensure that everyone is kept up to date with proposed changes and that where appropriate everyone is able to share their views. Discussions are also held about proposed activities and food menus. Excellent progress has been made in ensuring that residents are making informed choices and even if an activity cannot happen for a particular reason alternative arrangements can be made for it to happen at a different time. St Marks DS0000021225.V350793.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. Residents continue to lead very active lives with a very good balance between time spent on personal development, work and leisure. Improvements have been made in relation to the residents’ diets with greater emphasis on including more fruit and vegetables. EVIDENCE: Two of the residents continue to work for a couple of hours each week in a voluntary capacity. All but two of the residents attend either college, work or day centres throughout the week. Two of the residents chose not to attend these and one of these men is currently considering his options. He participates in a number of activities in-house and makes regular use of his local community. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 13 Two of the residents recently purchased a computer for their own personal use so now four of the residents have their own computer. In addition there is a computer available for use in the activity room. With the exception of one resident everyone went on holiday this year to the Norfolk broads. Those spoken with stated that they had a lovely time. Lots of photos were taken and residents enjoyed writing about the activities that they participated in within the residents’ charter. At the moment they are collecting ideas for next year’s holiday. A phone in the lounge area is available for use and can be taken to individual bedrooms for privacy. Staff stated that they are encouraging residents to use the phone independently without asking for permission to use it. Relatives spoken with stated that they have good communication with the staff at the home. One relative stated that there are very detailed arrangements in place to ensure that their son can travel independently to visit them and this works because of the good communication systems in place. Four of the residents have a weekly aromatherapy session. Some of the residents also take part in a social skills group. Residents enjoy regular trips to local pubs and those spoken with were able to identify which was their favourite local pub. One resident said the reason he likes the pub he chose was that he is known there and likes meeting up with other locals. One of the residents stated that they recycle as much as possible. The home is taking part in a composting scheme run by a local charity and it is hoped that as a result they will have a raised bed installed in the garden during the summer months. There are rotas in place dividing up some of the house tasks. Residents know what needs to be done and often just get on with it without any prompting. There was plenty of fruit available in the lounge area so that residents could help themselves without needing to ask. It was reported that whilst fruit has always been available for the residents, emphasis has also been placed on ensuring that there is a greater variety of fruit and that residents know that they can help themselves to it. Residents spoken with stated that they like having the fruit available. Menus for through the week are being discussed at house meetings and residents are being encouraged to try more vegetables. Progress with this is slower but will continue. Discussions at house meetings involve encouraging residents to state their favourite foods and least favourite foods. This concept has been difficult to grasp for some but progress is being made. At lunch time residents make their own lunches. Practices previously meant that residents assisted with shopping for the house but did not have responsibility for shopping for their own individual requirements. Now this is St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 14 more structured and they shop independently for their own lunch foods and there is a move to store individual food supplies separately. To date two of the residents have their own boxes to store their food. This system appears to be working well and it is hoped that this can be developed further. Menus through the week are set but at the weekly house meetings the menus from Friday to Sunday are decided. Residents usually go out or have a take away meal on Fridays. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements in place to ensure that the healthcare needs of the residents are met. EVIDENCE: Specialist advice and support is sought as necessary to meet the needs of the residents. At the time of inspection one resident was receiving input from a psychologist and an appointment had been made for this resident to see a psychiatrist. Close liaison with health care professionals was being maintained to ensure that the approach the home were taking in relation to this resident’s very complex needs was appropriate. Observations of staff and resident rapport were very friendly and respectful. It was evident that there is a strong bond between staff and residents. Staff support residents to attend healthcare appointments when necessary. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 16 The home uses a monitored dosage system for the storage of medication. At the time of inspection only one resident was prescribed medication although two residents use toothpaste that has been prescribed. Both residents manage this independently. Agreement has been reached with each resident’s individual doctor about the use of homely remedies. It is possible to carry out an audit of all medication from the time it is delivered to the home. Records show details of medication administered and a returns book is kept to document all medication returned to the pharmacy. If medication is given to a relative for a resident who is going on leave then a signing out/in book is kept to record this. All staff have received training on medication. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good procedures in place to ensure that anyone wishing to make a complaint can do so. EVIDENCE: There has been one complaint recorded since the last inspection. Records showed that the complaint was resolved satisfactorily. The complaints procedure is clear and details the steps to be followed when making a complaint. The procedure is on display in the home. The manager has spoken to residents during a house meeting about the subject of complaints and clarified the procedure to ensure that they are all aware of how to make a complaint. The complaint procedure is also to be simplified to ensure that this is even more user friendly. No complaints have been made to the Commission about this service. There is a detailed procedure in place on adult protection and prevention of abuse. There have been no adult protection alerts made in relation to this home within the past year. All but one of the staff team have attended inhouse training on the subject. St Marks DS0000021225.V350793.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. Residents benefit from living in a home that is well decorated, and the periodic environmental checks ensure that the standards of décor are maintained and the building is kept comfortable, clean and homely. EVIDENCE: Since the last inspection the ground-floor toilet has been completely refurbished and is now a shower room/toilet. Residents were consulted on the colour scheme and one of the residents made a mirror for the room. Residents spoken with were very pleased with the room. Unfortunately there are some damp patches in the room possibly caused by a lack of heat in the room. The manager advised that this matter has been raised with the owner and will be resolved in the near future. St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 19 The laundry area has also been refurbished and includes a new washing machine. In addition there is a new fridge/freezer in this area. The lighting in this room has also been replaced. Residents chose the colour scheme for this room and there is now a picture gallery in this area showing pictures chosen by the residents. The first floor bathroom has also been repainted and a new shower door has been fitted. There are plans for the redecoration of the hallway and stairwells in the coming two weeks. Residents have chosen to have paint rather than wallpaper and have identified the colour they would like in this area. All woodwork in this area is also to be painted. New door handles are to be fitted to the doors. The pool table is now permanently in the up to now unused area of the lounge. Residents stated that they like this arrangement. There are plans to upgrade the central heating system within the next year. An environmental checklist is carried out on a monthly basis. This involves identifying any works that need to be carried out and devising an action plan to address the issues. Where appropriate matters are raised with the owner. The format for recording this information is clear but completion dates for work addressed are not recorded. As a result of a recent visit from a fire officer the door covering the boiler in the kitchen had to be removed so this area is now left uncovered. An appropriate alternative needs to be put in place as leaving it uncovered also presents risks. A fire risk assessment was carried out in 2005. A checklist is carried out monthly to ensure that fire safety arrangements are in order. Fire extinguishers were tested in March 2007. Since the last inspection new door closures have been fitted to some of the communal doors. Door seals around some fire doors have also been replaced in line with advice from a local fire officer. The home are awaiting a further visit from a fire officer to check the safety measures in place. Fire drills are held regularly. Records showed that when they occur a full evaluation is carried out of the outcome. More recent drills do not include details of the time and length of each drill. All areas of the home seen were clean. Following the last inspection a review was carried out in relation to hand washing/drying. As a result liquid soap is now used and disposable hand towels are available in the bathrooms. St Marks DS0000021225.V350793.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. There are good training opportunities available to staff to equip them to meet the varied and complex needs of the residents accommodated. Further attention must be given to ensuring that staff have opportunities to attend autism specific courses and to ensuring that the Common Induction Standards are introduced. EVIDENCE: Records showed that the majority of the staff team are up to date with their mandatory training. The exception to this is first aid. Only one staff member has up to date training on this subject. The manager and two of the senior staff recently attended training on care planning. In addition the manager attended courses on the Mental Capacity Act, developing teams, managing complaints and safer food better business. None of the staff team have attended any autism specific courses in the past year. Records show that all staff receive regular supervision and staff confirmed that this is the case and that they find the sessions very helpful. A St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 21 recommendation was made at the last inspection of the home that the staff induction package be updated to comply with Skills for Care’s Common Induction Standards. This has yet to be achieved. However, all the new staff complete the current induction package. Since the last inspection recruitment procedures have been revised and all administration relating to recruitment is carried out at the head office. Records were seen in relation to three staff recruited since the last inspection of the home. One of the staff has yet to commence working in the home. Recruitment is thorough and full checks are carried out on all staff. In relation to one file there was only one reference in place. Staff advised that this would be followed up immediately. Prospective staff attend a first stage interview at the head office. Those selected then go on to attend a second stage, working interview at the home. This is an opportunity to meet with the residents and feedback is also obtained from the residents on their views about the prospective staff member. POVA first checks are carried out and a full CRB is in place before new staff commence working in the home. The manager confirmed that with the exception of one member of staff all of the staff have completed NVQ level three and the staff member that has not completed level three has completed level two and is about to start studying for level three. St Marks DS0000021225.V350793.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. Health and safety arrangements are thorough minimising the risk of accidents and incidents. Although it is evident that the owner is monitoring the running of the home the need to recommence carrying out monthly reports is essential. The manager needs to apply for registration as manager. EVIDENCE: The manager has been in post for almost a year but has yet to be registered. She is currently studying for the RMA (Registered Manager’s Award). Staff spoken with described her as supportive ‘will state her views on topics but is open to new ideas’. Another staff member stated that since taking up her St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 23 position one of the main achievements the manager has made has been ‘to empower the residents to make more informed choices and decisions’. Staff meetings are held regularly. Minutes show that a variety of subjects are discussed and that staff are encouraged to share their views. A staff member spoken with stated that the meetings are a good opportunity to hear other staff views and there is now an agenda in advance of each meeting so that you have time to think about topics in advance of the meeting. Management meetings are held periodically, the last meeting being held in September 2007. As part of the home’s quality assurance system a monthly monitoring report is carried out. The last record seen was dated for June 2007. Records showed that the manager was dealing with issues that needed addressing and discussing relevant topics with the owners as a result. Satisfaction questionnaires have not been issued this year. The reason for the delay is that the manager is reviewing how they seek information and is in the process of setting up a consultation with relatives to open up a debate on how they can be more involved in this process. Following this process a new system will be introduced. Residents’ views are sought weekly as part of the house meeting. It was reported that the company has a five-year development plan but there is no annual development plan in place for St Marks. Following the inspection of the home contact was made with the relatives of two of the residents. Comments received were very positive and included ‘ the home are very supportive to our son and to us, my son says that staff are kind’, we are very content with the service our son receives, ‘we have never had any serious issues and the staff bend over backwards to accommodate us’, ‘all the staff are excellent and we know that if we ask for anything it will be carried out’, ‘we wouldn’t find better anywhere else’. The manager confirmed that portable appliances have been tested within the past year. One of the residents assisted in this process. One of the resident’s assisted the inspection by checking hot water temperatures at three outlets. All readings noted were within agreed safety limits. The home’s policy and procedure manual has been updated in the past few months. The provider or a representative on his behalf is required to visit the home on a monthly basis unannounced and to carry out a report on the running of the home. Records show that two reports have been carried out since the last inspection. The provider does however, visit the home once a week. St Marks DS0000021225.V350793.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 2 2 X 3 X 4 X 5 X 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 2 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 4 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 3 3 X X 3 2 St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 25 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 Regulation 6(a,b) Requirement The home’s statement of purpose must be updated to reflect the changes in the management team. [This was a requirement of the previous inspection, timescale given was 15/04/07] The care plan and guidelines in place for one resident must detail the approach and action to be taken whether the resident is well or unwell. The damp patches in the shower room must be investigated and action taken to prevent further damage to this area. Staff must receive training on first aid. The acting manager must apply for registration. [This was a requirement of the previous inspection, timescale given was 30/04/07]. Timescale for action 31/01/08 2. YA6 15(1) 31/12/07 3. YA24 23(2b) 31/01/08 4. 5. YA32 YA37 13(4) 9(1,2) 30/12/07 31/12/07 St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 26 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 The home should complete the updating of the service user guide. [This was a recommendation of the previous inspection]. The home’s induction package should be linked to Skills for Care and new staff should complete the package within twelve weeks of employment. [This was a recommendation of the previous inspection]. 2. YA35 St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 27 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 St Marks DS0000021225.V350793.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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