Inspection on 04/01/06 for The Goodwins

This inspection was carried out on 4th January 2006.

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

The inspector found 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Goodwins 22/06/07

The Goodwins 22/08/06

The Goodwins 20/09/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Goodwins 3 St Richards Road Deal Kent CT14 9JR Lead Inspector Mary Cochrane Announced Inspection 4th January 2006 09:30 The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Goodwins Address 3 St Richards Road Deal Kent CT14 9JR 01304 389149 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) CareTech Community Services (No.2) Ltd Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: The Goodwin’s is registered to provide 24-hour residential care for up to 8 adults with learning difficulties. At present there are 7 Service Users in residence. The Home is located in a residential area on the outskirts of the costal town of Deal. There are public amenities and good transport links close by. The property is a substantial detached house with a parking facility to the front. The accommodation is arranged over two floors. All of the Service Users have their own bedrooms and all of the rooms have washbasins. There are three bathrooms, a large communal lounge, a small lounge area, conservatory, dining room and a kitchen. There is a large garden to the rear of the property, which is well maintained for Service Users to enjoy in the better weather. . The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the 2nd inspection at The Goodwin’s this year. This visit was announced and lasted from 9.30a.m until 4.00 p.m. The majority of the key standards were looked at earlier in the year, so the inspector focused on the requirements and recommendation identified in the previous report and the outstanding key standards. The homes manager is now registered with the CSCI. He was available throughout the day and was well prepared for the visit. The registered manager is taking positive steps to meet the standards and regulations that are required of the home. At the time of the inspection it was found that the home still has some work to do but the staff are working hard and moving in the right direction. At the time of the visit there were 7 service users in residence. All the service users at The Goodwins have complex learning disability needs and have difficulty in communicating. They all require skilful management and care. During the inspection the atmosphere in the home was calm and the service users seemed settled and content. Activities were taking place and staff were seen to be interacting and engaging service users in a positive and caring manner. The staff on duty at the time of the visit were helpful and cooperative. The following methods of inspection and information gathering were used: one-to-one discussion with staff, observing interactions, care interventions and activities, reading and discussing individual support plans, risk assessments, selected policies, medication protocols, staff files and training programmes The inspector also looked at the homes procedures regarding the service users finances. 27 of the standards were looked at. 7 requirements have been made and 3 recommendations. What the service does well: The registered manager should be commended on the amount of work he has undertaken towards meeting all of the national minimum standards. There have been significant improvements at the home since his appointment. The registered manager is showing a clear sense of direction and leadership, which staff are able to relate to and the service users benefit from. The staff do meet the physical needs of the service users and the staff on duty were seen to interact in a caring and nurturing way. Service users were seen to be treated with dignity and respect. The care plans and risk assessments are of a good standard and the information contained in the care files is informative and helpful in assisting The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 6 staff to deal with the complex needs of the service users. The staff are able to anticipate any challenging behaviours and few behavioural incidences have taken place. There have been no reported incidences to the CSCI since the new manager has been in post. What has improved since the last inspection? What they could do better: Each individual service users requires an individual activities programme. The registered manager is in the process of undertaking the groundwork to ensure that each of the programmes is developed so that they are suitable to meet the individual needs of the service users. The registered manager hopes that this task will be completed by the next inspection. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 7 The home needs to continue with its environmental improvements so as to provide a well maintained homely and pleasant environment for the service users. The registered manager needs to continue to try and engage and involve outside professionals and specialist so the service users can benefit from their skills and input. The staff at the home still require a safe place to store their belongings when they are at work. The company needs to develop specialist training for the staff to increase their skills to enable them to meet the complex needs of the service users. The staff at the home continue to report that they need more staff per shift to ensure that the needs of the service users are met at all times. The registered manager needs to continue to try and identify dedicated care managers for each of the service users so these issues can be discussed. The registered manager also wants to improve and develop how staff organise their time at the moment. 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 Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 8 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 The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 9 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): Standards 1,2,3 were looked at and met at the previous inspection in September ’05. There have been no new admissions to the home in the interim period. EVIDENCE: The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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): 6,7,9 &10 There is a consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Service users are able to make decisions about their own lives and assisted as necessary Risks are identified, recorded and minimised ensuring that service users are protected and kept as safe as possible. EVIDENCE: A sample of care plans were looked at during the visit. The care plans are of a good standard and reflected the changing needs of the service users. They contained all the required information including medical and specialist needs, approaches to personal care, behavioural interventions, eating and drinking needs Each of the service users has an allocated key worker and the staff reported that they use the plans as a working document, they were able to explain how they use the care plans to benefit the service users. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 11 A lot of information is kept on each of the service users files. It was discussed with the registered manager that maybe some of the information is not relevant to meeting the needs of the service users and that the files could be streamlined to make them easier to use and manage. The registered manager is going to look at this but first wants to make sure that the home has a robust system in place for ensuring the needs of the service users are met. At this inspection there was evidence to show that 6 monthly reviews are taking place for each service user conducts an internal 6 monthly review. The home is able to evidence how each of the service users makes decisions and choices as part of their every day live and how they are assisted and supported by staff. The service users have daily one to one meetings with the key workers, which are recorded. There was clearly documented evidence to show how decisions were made with regards the activities the service users wanted to do. Any limitations and restrictions are recorded in the individuals care plan. Service users are encouraged to do as much as possible for themselves, choosing clothes, shopping for their rooms. They are also encouraged to help keep their rooms clean, wash and put clothes away. The registered manager and care staff encourage and support the service users to live an independent lifestyle as their abilities allow. There are risk assessments in place, which are individualised and provide information on how to minimise identified risks, these are of a good standard and are up-dated as required. It was evidenced at the visit that all information pertaining to the service users is kept securely at the home. The staff office is locked if it is unoccupied. Staff were seen to respect the confidentiality of the service users. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 &16 The home is developing and has started to provide the service users with opportunities and facilities that enable them to maintain an appropriate and fulfilling lifestyle in and outside the home. This will encourage and support them to reach their full potential. EVIDENCE: Since the last visit the registered manager has implemented significant developments and improvements to ensure that the service users have begun to receive a lifestyle that is fulfilling and active. This was evidence by looking at documentation, talking to staff and through observation. Service users are being offered and encouraged to participate in meaningful activities and leisure pursuits. Staff reported that they were surprised at what some of the service users have achieved in a short period of time and this have given them the motivation and incentive to carry on with renewed energy and enthusiasm. The home has now employed a member of the care staff team to act as activities co-ordinator for the home. He works Monday-Friday 9.30a.m – 5.00p.m and is developing a programme of activities for the service users. This is yet to be fully developed and implemented. They staff are in the process of The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 13 discovering what the individual service users like and dislike and what activities they benefit from and what is successful or unsuccessful. The registered manager has a clear vision and realises the importance of undertaking thorough groundwork before individual activities programmes are formulated. The registered manager still needs to ensure that any specialist plans that have resulted from previous specialist interventions are actioned and outcomes recorded and fed back given to the appropriate service. He has now met with the local learning disability team and the inspector acknowledges that this is a start re-engaging with the specialist service. Service users are given the opportunity to fulfil their spiritual needs. During this inspection staff were respectful of the service users’ privacy and dignity and most of the staff on duty were seen to be inclusive on interactions within the home. The service users have unrestricted access throughout most of the communal areas and are escorted by staff members into the kitchen and dining room as these are areas of risk. The registered manager needs to ensure that there is a risk assessment in place to evidence why there is an infringement for service users when they want to access the dining room and kitchen. Service users can choose when to be alone or in company, and when not to join in activity. Staff respect the private space of the service users. Any restrictions are documented in individual plans and rationalised. The service users are encouraged to undertake tasks within the home. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 The home provides appropriate personal and physical healthcare for the service users promoting personal support and good physical care. The home needs to provide adequate specialist input for the service users to ensure the health and welfare of the service users is maximised. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure the service users medication needs are met. EVIDENCE: The Home operates a key worker system to provide sensitive and individual support to service users. Personal care, life skills and dignity are promoted. Service users are assisted to choose their own clothes and are supported to shop. There is a flexible approach to daily living activities e.g. getting up, bed, bath and mealtimes. Staff were seen to approach service users in a caring and nurturing manner. It was observed that the service users privacy and dignity was maximised allowing them independence and control of their own lives. The staff reported that the service users have a choice of staff who work with The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 15 them. Some service users get on better with some members of staff and this choice is respected and encouraged. Since the last inspection the registered manager has had a meeting with the manager of the local learning disability team. The out-come of the meeting was that the local disability team are going to gather together and provide the home with all the information, plans and programmes they have developed for the service users in the past so that they can be re-introduced and implemented for the service users. When this has been achieved it will then be discussed as to whether or not the Learning disability team will become reinvolved with the home. The home has established contact with a speech therapist and a physiotherapist but the in-put has been one-off visits. The service users do need a more consistent and regular input from specialists. The registered manager is aware of this need and is trying to engage the appropriate specialist. One service user is on an extensive waiting list for psychology input. All the service users at the home have now been seen and are regularly reviewed by the local consultant psychiatrist. All service users now have regular appointments with their G. P. The staff ensure that the service users have access to healthcare facilities and routine checks are carried out frequently. Health care needs are monitored and they are referred to professionals when necessary. A member of staff accompanies service users when they are attending appointments and visits from healthcare professionals are conducted in private. A medical report sheet is maintained by the home to evidence dental, chiropody, G.P. and other health care appointments. There is regular input from one G. P. at the local surgery offering a supportive and consistent approach in meeting health needs. The home continues to have robust procedures in place for the administration of service users medication. The company has recently reviewed its policy on the administration of medication. One senior member of staff now administers and signs for the medication, were previously it was two. Senior staff have received the necessary training and have been observed dispensing the medication before the new procedure was implemented. Staff competencies will now be reviewed at regular intervals. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 the following standard(s): 22 & 23 The home has a satisfactory complaints system. Service users are protected from all forms of abuse. EVIDENCE: The home does have a satisfactory complaints procedure clearly outlining the different stages for making a complaint, and how to contact the Commission. The displayed complaints procedure contains all the necessary information. The home has received no complaints since the last inspection. The home has the appropriate Adult Abuse policies in place and also a Whistle Blowing Policy. The staff are aware of the policy, felt confident to use if necessary and knew the appropriate action to take if they had to do so. Any incident pertaining to abuse would be followed up immediately and all action taken recorded. The registered manager is aware of the POVA lists. The home has developed a system of managing service users monies, which protects them from abuse. The home provides a safe place for the storage of monies and valuables. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 The standard of the environment within this home is improving. The home needs to continue with its on-going maintenance and refurbishment plans so as to create an environment that is homely and comfortable. EVIDENCE: The Goodwins continues with its environmental improvements. On going refurbishment and redecoration needs to continue. The area leading from the lounge, which was previously a wasted space now provides a snoozelam area which service users use regularly. The area has been carpeted and the doors re-hung so the area can be made private and conducive for the purpose it is now intended for. The staff reported the snoozelam area has proved successful with the service users and they hope to further develop the space. It is also used for arts and crafts sessions and also as a de-escalation area. The conservatory leading from the lounge is old and past its best. It is not a very pleasant or welcoming area due to its state of repair and age. The area is used only occasionally for craft sessions. The service users would benefit from a replacement conservatory that was homely comfortable and welcoming. The downstairs bedroom, which had a damp patch between the cornice and picture rail, has been made good. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 18 The strong odour from the floor sealant in one of the bedrooms is now fading. During this visit the inspector did detect a strong odour in another bedroom, the registered manager reported that this room is due for refurbishment and redecoration, which will include replacing all the furniture. The Home has systems and a rota in place to maintain a clean and hygienic environment and prevent the spread of infection. On the day of the inspection the home was tidy and clean. The manager is going to look at ways in which he can evidence that the cleaning tasks are undertaken at the required intervals. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 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 The staff have a good understanding of the service users and positive relationships have been formed. The staff group within the home is now stable. The arrangements for the induction of staff are good. Staff have received the required training required by the national minimum standards. More specialist training needs to be in place to ensure that all staff have the skills and competencies to meet all the needs of the individual service users. The procedures for recruitment are robust and could leave the service users at risk. EVIDENCE: At the last inspection the outcome of these standards was an area of concern; this was highlighted in the previous report. It was evidenced at this visit that there have been a significant improvement. The care staff employed by the home are all issued with a job description on starting employment. The turn over of staff has reduced and the work force is more static and approaches to service users needs and behaviours are more consistent. There was evidence to show that the staff are able to promote the main objectives of the home and are aware of their role and responsibilities and that of the other staff. The staff reported that they have developed good relationships with the service users and they are able to anticipate and meet The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 20 the individual needs of the client group. The staff reported that they have developed a good working relationship with the registered manager. There are no volunteers going into the home at the present time. It was observed that the staff on duty were accessible and approachable to the service users and were seen to be communicating and interacting effectively. It was evidenced at this visit that the staff on duty put the needs of the service users first. The home employs 12 members of care staff. The home aims to have 5 members of staff on in the morning and 4 in the afternoon. The new activities co-ordinator works between 9.30-5.00 p.m. Monday to Friday. The duty rota reflected this and the staff also confirmed it. The staff reported that they still feel that they need more care staff per shift to assist and support the service users to reach their full potential. The registered manager is looking at ways in which staff time is managed to get maximum efficiency from the amount of staff he has at the moment. The home continues to employ agency staff but only use staff who know the home well. The inspector spoke to 5 members of the care staff team and they all reported improvements in the home. They are now doing a lot more activities with the service users both in-side and outside the home, which are more constructive and fulfilling. They reported that service users have achieved things that have not been done before and feel more positive about the home. They are now working together more, as a team. The staff spoken to said that they now feel more supported and are receiving the direction and guidance they need to carry out their jobs effectively. Everyone felt that the moral amongst the staff has improved and staff are keen to improve the home to ensure the needs of all the service users are met. It was evidenced at this inspection that the home has reached its 50 targets of care staff trained to NVQ level 2 and above. All staff have received the necessary mandatory training. The 2 new staff have received the necessary induction and have commenced their mandatory training, which will be completed within the 6 month timescale. The registered manager needs to look at developing more specialist training to ensure that the staff have the knowledge to enable them to develop their skills in meeting the more specialist needs of the individual service users. The home has a system in place, which identifies the training needs of the staff. This ensures that all training is up-to date and on-going. The home has monthly staff meetings, which staff reported are beneficial and positive. The registered manager is going to ensure that there is evidence available to monitor the outcomes of the meetings. The inspector looked at a sample of staff files. The recruitment procedures within the home are thorough and robust. All staff receive regular supervision. The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 21 The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 & 43 The home has a registered manager in post who provides leadership, guidance and direction to ensure the service users receive a consistent quality of care. Quality assurance and monitoring needs to be further developed to ensure the aims and objectives of the home are being met and the views of the service users/representative are acted on. There is no evidence available to demonstrate that the service users are benefiting from an effective, financially viable and accountable service The health, safety and welfare of the service users is promoted and protected EVIDENCE: The manager of the home has been in post since February ‘ 05 and became registered with the CSCI in November. He is learning very quickly what is required and expected of him to undertake the role of registered manager. He The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 23 is taking the necessary steps to achieve competency and good practise within the home and is also working towards complying with the Care Standards Act and Regulations, GSCC codes of practice and other legal requirements. He is also undertaking the NVQ level 4/RMA, which he hopes to complete this year. At the time of the inspection the manager was able to communicate a clear sense of direction and leadership, which the staff and the service users responded to. The staff reported that they were well supported and service users responded in a positive, relaxed manner in the presence of the manager. Opportunities for change and development were on going. The home has started to develop effective quality assurance and quality monitoring systems. Because all the service users have difficulty communicating their views are being sought daily in one to one talk times and a record is kept. Changes are being made as a result of this. The views of the service users are being acted on. The home receives a thorough comprehensive audit every 6 months and recommendations for improvement are made. The views of family, advocates and others who have input into the home needs to be sought on how the home is achieving goals for service users. Out-comes of all the quality assurance and monitoring need to be evidenced. The home was not able to produce an annual development plan reflecting the aims and out-comes for the service users. Mandatory training is now almost up to date and dates have been booked for training that is out-standing. The home was able to produce evidence of accidents and injuries sustained on the premises, which are all in order. Environmental risk assessments are available. Gas and electric maintenance was up to date and PATS tests have been done. The home has recently received new guidance on doing water temperature tests. These are to be done monthly and any deviation from the required temperatures has to reported and dealt with immediately. All the necessary fire and equipment tests have been completed. Following the last report the homes vehicle MOT and service history had been evidenced. At the time of the inspection the vehicle was in for repair. The home will be acquiring a new minibus in the near future. There was no evidence available at the home at the time of the inspection to show the overall management, effectiveness and accountability of the service. The home is required to produce as evidence an annual business and financial plan for the home and the service, which the CSCI can inspect at times of visits. Systems need to be in place to ensure financial planning, control and budget monitoring. Lines of accountability within the home and with the external management need to be clearly understood by service users and staff. The home insurance certificate was seen and was up to date The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 2 X X LIFESTYLES Standard No Score 11 1 12 2 13 2 14 2 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Goodwins Score 2 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 3 1 DS0000065342.V256942.R01.S.doc Version 5.0 Page 25 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 Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA11 & YA18 13(1)(b) Regulation 16(2)(m) Requirement The registered manager needs to access more specialist in-put and interventions for the service users. Out-comes of the interventions/programmes of care need to be documented and implemented and outcomes recorded and reported on. (Outstanding requirement from the previous 2 inspections. Timescale of 31/11/05 not met) One of the bedrooms at the home has a distinct unpleasant odour. It needs to be ensured that the home is kept free from offensive odours. The kitchen and the dining room need improvements and redecoration. (Outstanding requirement from the previous inspection. Timescale of 30/12/05 not met) The staff require safe storage facilities for their belongings. (Outstanding requirement from the previous 2 inspections. Timescale of the 30/11/05 not met.) The registered manager needs to DS0000065342.V256942.R01.S.doc Timescale for action 30/04/06 2. YA24 16(2)(k) 30/04/06 3. YA28 23(2)(b) 31/05/06 4 YA28 23(3)(ii) 30/04/06 5 YA37 9 30/06/06 Page 26 The Goodwins Version 5.0 complete his NVQlevel4/RMA 6 YA39 24,26 The registered manager needs to 30/04/06 ensure that there is an annual development plan in place specifically for the home and that quality assurance systems are developed. Service Users are to benefit from 30/04/06 competent and accountable management of the service and the inspector requires to see evidence of this when visiting the home. 7 YA43 25 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 Good Practice Recommendations Standard YA12YA13YA14 The registered manager needs to ensure that activities, leisure pursuits and involvement with the local community continues to develop. All the service users need an individual activities programmes which meets their individual needs and preferences YA28 The conservatory area in the home needs up-grading to provide a pleasant and conducive area for service users to use and benefit from. YA32 The staff need to develop their specialist knowledge and skills to meet the needs of the individual service users. 2 3 The Goodwins DS0000065342.V256942.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Kent and Medway Area Office 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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