Inspection on 06/02/08 for Woodbridge House

This inspection was carried out on 6th February 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodbridge House 30/01/09

Woodbridge House 07/09/07

Woodbridge House 28/02/07

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Insight - Eastchurch

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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 Woodbridge House 151 Sturdee Avenue Gillingham Kent ME7 2HH Lead Inspector Joseph Harris Key Unannounced Inspection 6th February 2008 09:00 Woodbridge House DS0000068213.V359575.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 Woodbridge House DS0000068213.V359575.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. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodbridge House Address 151 Sturdee Avenue Gillingham Kent ME7 2HH 0208 502 4466 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) www.achuk.com Aitch Care Homes (London) Ltd Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) The maximum number of service users to be accommodated is 10. Date of last inspection 7th September 2007 Brief Description of the Service: Woodbridge House is a large detached corner property situated on the outskirts of Gillingham town centre. The home can accommodate up to 10 service users aged between 18 and 65 with a learning disability and complex needs. The home is on a main bus route and the Gillingham town centre main line railway station is approximately 1 mile away and has easy access to the local library, shops and other facilities. The fees range from £1,300 to £1,550 per week Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection process culminated in a site visit to the home on 6th February 2008. The site visit commenced at approximately 10am and concluded at 4.30pm, lasting for around 6.5 hours. During the course of the visit a tour of the premises was undertaken and discussions were held with the registered manager, staff members and service users. A range of documentation was examined relating to the residents, staff, medication, health and safety and the day-to-day running of the home. What the service does well: What has improved since the last inspection? A new home manager and a Regional Operations Manager have been appointed since the last inspection and have instigated many improvements in this time. The record keeping and administration in the home has improved ensuring that key documents are easily accessible and old records archived. The manager and staff have reviewed and started to update care planning and risk assessment processes. These documents now provide clearer guidance to Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 6 staff addressing the needs, expectations, aims and risks for individual service users. Fire safety systems have improved with a current fire risk assessment and regular fire drills taking place. Health and safety records in general are now well managed and all relevant checks completed. Work has begun to develop a more comprehensive activities programme based on the individual needs of service users. Behavioural strategies have been developed to ensure that people who use the service are protected from possible forms of abuse. The Regional Operations Manager has introduced a more robust and actionfocussed quality monitoring system including comprehensive monthly monitoring visits. What they could do better: 2 requirements and 5 recommendations have been made as a result of this inspection process. 1 requirement regards the new manager who has been in post for around three months and is the fourth manager of the home since September 2006. She needs to progress through the registered manager process with the Commission for Social Care Inspection. The second requirement relates to staff training. According to the staff training matrix a number of staff members have not completed all required mandatory training. Additionally training issues specific to the needs of service users such as mental health awareness and communication should also be provided to all staff ensuring that needs can be met in a consistent fashion. The recommendations focus on areas of work that have begun to show levels of improvement, but, as acknowledged by the manager, would benefit from further development. A number of the staff team have not yet received all the required mandatory training or would benefit from updates. This has been identified by the home and training is in the process of being organised to address these shortfalls. Further work to continue to develop care planning and risk assessments would be beneficial and is an area of priority identified by the manager. There was noted to be some gaps in the weekly and monthly in-house monitoring of fire safety systems. Recruitment checks are well-managed, but further work could be completed to ensure a full employment history is gained for all new staff. The statement of purpose and service user guide require minor amendments to ensure that they are up to date. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 7 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. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 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 Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Quality in this outcome area is good. Prospective service users are able to make an informed choice about moving into the home and their needs are assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose, which is a detailed document setting out the aims and facilities of the service. There have been a number of managerial changes over the past 12 months and the statement of purpose should be updated to reflect these changes. There is a service user’s guide, a copy of which is given to all prospective service users. The guide has been developed using written text, pictures and symbols to aid understanding. There is scope to develop the accessibility of this document further, however the current format is suitable for the purposes of the home. Amendments are also required to this document reflecting the managerial changes in the home. Refer to recommendation 1. All referrals to the home are initially screened through a central referrals team. The manager stated that she does sometimes receive referrals directly, but passes these onto the referrals team. There has been one new resident since the last inspection and the assessment information for this individual was Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 10 completed in good detail providing a comprehensive and holistic assessment of needs, risks, expectations and goals. Following the initial referral the manager and/or senior staff visit the prospective service user in their current accommodation, which, if appropriate, leads to trial visits to the service based on the individual needs and requirements of the prospective resident. The trial visits initially start with the offer of a short visit leading to longer daytime stays and overnight stays if desired. There have been occasions when emergency admissions have been accepted into the home, but the manager and staff team ensure that all assessment and planning is completed in a timely fashion. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 11 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): 6, 7, 9 and 10. Quality in this outcome area is good. There are individual plans of care and risk management plans in place for all service users. Residents are able to make decisions affecting their day-to-day lives with support as required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has started to develop the quality of individual care planning. The new manager stated that she intends to improve these further over the coming months with the aim of embracing personcentred planning and a more proactive approach to support plans. Three individual service user files were examined. The files have been reorganised and working records are now located in logical order with archived information either removed or stored at the back of the file. The individual plans clearly address care and support needs linked to assessment information Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 12 and take into account current and changing needs. There remain elements of the plans that could still be developed. The plans could focus more on the support to develop independent living skills, communication needs and, in one case, clearer guidance for managing and monitoring mental health issues. Refer to recommendation 2. The manager is in the process of introducing a new method of support planning. Examples of this were examined, which provide clear, accessible and focussed plans of care promoting consistency and guidance for staff to assist service users. The plans are reviewed at least every 3 months and more frequently if required. The home/organisation does not take an appointee role in respect of any service user’s finances and these are managed independently of the service where a resident is deemed not to have capacity in this area. Residents are able to make decisions affecting their daily lives. There is access to information regarding advocacy services. Staff were observed to promote decision-making by encouraging and offering people who use the service choices in all aspects of their daily lives. The manager has also reviewed and updated the risk management and assessment processes in the home. Clear risk assessments are in place for all service users. Behaviour management strategies are in place addressing challenging behaviours and individualised physical intervention plans are developed where required. Risk management plans are reviewed regularly and adapted as perceived risks change. The new risk management system includes a score based on likelihood and consequences of risk. It is advised that a key to the scoring system is included on all risk assessments to aid understanding in this area. Refer to recommendation 3. All information held within the service is maintained in a confidential manner and staff address issues of confidentiality through the induction process. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. Residents have access to a varied lifestyle that includes a range of choices both in and out of the home. The quality of the food in the home is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service have opportunities to engage in a range of activities in and out of the home. In discussion, the manager stated her intention to concentrate on providing a wider variety of activities based on individual needs and preferences over the coming months. At the current time service users can participate in clubs, day centres, colleges and other local facilities with the support of the staff team. Some activities are brought into the home for those less able to go out such as arts and crafts sessions. There is a sensory room in the house that is being encouraged to be used more by the residents. Some staff expressed the view that they would like to see more Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 14 1:1 activities in the home and an increase in trips to the cinema, swimming, bowling and other recreational pastimes. The manager is developing activity planners with all service users to identify areas of interest and aspects of the activity programme that can be expanded. The home is situated within a reasonable distance of the town centre and other local facilities and the staff spoken with demonstrated a good awareness of the resources available locally. Visitors are welcomed into the home at all reasonable times and the manager stated that the intention of the home is to ensure that families and friends feel included as appropriate. It was not possible to meet with any visitors during this inspection process. The daily routines and preferences of residents are respected by the staff team with regard to all areas of daily life such as times for getting up, going to bed, meal times and choices. All residents are offered a key to their rooms unless otherwise assessed. Staff knock before entering rooms and were seen to interact with residents in a relaxed and respectful manner. Residents stated about their views of the home saying, “I’m happy” and “I like it here” amongst other comments. The quality of food in the home is of a good standard. There is a well appointed kitchen and food stocks were in adequate supply and of good quality. Residents are involved in planning menus and some residents assist with menu planning and, in some cases, shopping for and preparing the food. Menu records are maintained showing that choices at each mealtime are provided. Woodbridge House DS0000068213.V359575.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): 18, 19 and 20. Quality in this outcome area is good. Service users receive personal and healthcare support in a way that they prefer and meets individual needs. Medication practices are safe and well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service are supported to make choices about their day-today lives. Individual service user plans have improved to set out the preferences with regard personal support. However, further development in this respect would be beneficial focussing on person-centred needs and supporting effective communication with some people who use the service. One staff member stated that boundary setting could be improved to ensure that all staff are working consistently with service users. Another staff member felt that they would benefit from clearer guidance and training to support a service user who has some mental health issues. This would promote a consistent approach to managing these issues and enable all staff to respond Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 16 effectively to these individual needs. One resident said, “The staff are good.” Another service user said, “I get help when I need it.” There is a key worker system in place and the new manager is developing stronger roles in this respect. Additional specialist support is provided as required such as occupational therapy, physiotherapy, speech therapy and dieticians, etc. Some staff members have received training in non-verbal communication such as Makaton. It would be beneficial to develop this training based on the individual requirements of the service users to promote effective communication at all times. Refer to requirement 1. There is evidence that the healthcare needs of service users are met. Records are maintained of all appointments and consultations. Any healthcare issues are appropriately referred. Each resident is registered with a local GP and it was reported that there are good links established with local community learning disability teams. Residents are supported by staff to access healthcare appointments. Supplementary healthcare needs are monitored through regular visits to dentists, opticians, chiropodists, etc. There is adequate space in the home to ensure that service users can receive visits from medical practitioners in private. The medication storage facilities have been relocated to provide greater levels of security and privacy. All medication records were well maintained and the storage of medicines well managed. Staff who administer medication have received training in this respect. Staff administer medication in pairs to reduce the risk of medication errors. There are clear policies and procedures in place and a copy of the Royal Pharmaceutical Society guidelines for the administration of medicines in care homes on site. Woodbridge House DS0000068213.V359575.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): 22 and 23. Quality in this outcome area is good. Service users and their representatives are listened to and views acted upon. People who use the service are protected from forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home and organisation have clear complaints processes in place, a copy of which is provided to all service users/representatives. The manager stated that she aims to address all initial concerns on an informal basis if possible in the first instance, but should this prove unsatisfactory then formal complaints processes are followed. It was reported that there have been no complaints since the last inspection. Clear policies and procedures are in place relating to safeguarding vulnerable adults and protection against forms of abuse. New staff are instructed in these principles through the induction programme and additional training in this area is provided. The majority of staff have completed this course and further training is planned for the coming months. There are low levels of physical interventions occurring in the home, but where there is a perceived risk necessitating such action individualised strategies have been introduced. Staff receive management of aggression, de-escalation and physical intervention training. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 18 The manager stated that she has recently referred one issue to the Safeguarding Vulnerable Adults team, which is being assessed. However an Adult Protection investigation has not been instituted with regard to the issue. Woodbridge House DS0000068213.V359575.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. The home is suitable for the needs of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodbridge House provides a safe, comfortable and homely environment that is able to meet the needs of the people who use the service. The home has been established for approximately 18 months and was completely refurbished and redecorated prior to opening and benefits from good quality furnishings and fittings. As a result the premises are well suited to the needs of the people who use the service. There is a good range of communal space including a large lounge, sensory room, a quiet room and dining room. The garden is enclosed and accessible to all with a ramp leading to a lawn with garden furniture. All of the bedrooms are single occupancy and residents are encouraged to personalise their rooms as they wish. One service user said, “I Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 20 like my room.” There are suitable toilet and bathroom facilities conveniently situated throughout the home. The kitchen is well-appointed and laundry facilities are suitable for the needs of the home. All hazardous substances (COSHH) are securely and safely stored. It was reported that the home meets the requirements of the environmental health and fire departments. Woodbridge House DS0000068213.V359575.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. Service users are supported by a competent staff team recruited following appropriate policies and practices. Staff training requirements need further development to ensure that mandatory training is up to date and instruction is provided in issues specific to the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Open discussions were held with a number of staff members on duty throughout the course of the site visit. It was evident that there is a good understanding of the needs of service users and a commitment to supporting people who use the service in a positive manner. Staff were able to talk openly about the strengths and limitations of the home demonstrating awareness of the aspects of the service that they would like to see improve and develop. The majority of care staff in the home have achieved a National Vocational Qualification (NVQ) level 2 or above. Some staff are now working towards higher awards in this respect. Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 22 2 staff personnel files were examined that contained all the required information including CRB checks, proof of identity, two written references and completed application forms. It was noted that further work could be completed to ensure that there is a full employment history for newly recruited staff including periods of unemployment. In one case there was a gap of approximately 2 years unaccounted for and no evidence to show that information had been received through the interview process to account for this time. Refer to recommendation 4. The organisation has a comprehensive training programme for all staff using centrally organised and external training providers. An up to date staff training matrix was examined, which demonstrated that not all of the staff working in the home have received the required mandatory training or would benefit from updated training. The manager stated that a priority is to ensure that all staff are fully up to date in respect of foundation training and training needs specific to the home, such as mental health awareness and communication. The provision of additional mental health training would promote consistency and understanding whilst supporting individuals with complex needs in this area. Additionally instruction in respect of communication needs would enable staff to identify and address the needs and wishes of service users with difficulties in this area more effectively. Refer to requirement 1. The home uses a combination of Common Induction Standards and an in-house induction programme to ensure that fundamental issues are addressed in the early stages of employment. Additional service specific training is provided to staff in the home and the manager acknowledged that training issues are an area that she aims to develop over the coming year. Woodbridge House DS0000068213.V359575.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. There is a new manager in post who needs to be put forward for registration with the Commission for Social Care Inspection. Improved quality monitoring processes have been developed. The health, safety and welfare of service users is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has been through a number of managerial changes in a relatively short space of time, which, it was acknowledged by the manager, has hindered the anticipated development of the service. However, a new manager was appointed in November 2007 and she has demonstrated, in a relatively short Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 24 space of time, a clear focus and direction for the home. She has many years of experience in the field of social care having held managerial posts in the past and has instigated the review and improvement of a number of shortfalls highlighted at the previous inspection. She demonstrated a clear understanding of her priorities for the overall development of the service and strategies to address these issues. However it is essential that evidence of sustained improvement be provided to the Commission for Social Care Inspection to demonstrate that these issues can be consistently maintained and developed. Some staff views echoed this with comments such as, “The home is improving, but there are still things to do.” The home would benefit from sustained and consistent leadership due to the fact there have been 4 managers in the 18 months since the service was registered. This was underlined by the fact that a number of staff members commented on low staff morale due to a feeling of constant change and lack of leadership in the home. The manager needs to apply for Registered Manager status with the Commission for Social Care Inspection demonstrating a commitment to remain at the home for the long term. Refer to requirement 2. The organisation has appointed a new Regional Operations Manager who visits the service on a regular basis completing comprehensive monthly Regulation 26 reports. This has ensured that requirements and recommendations from the previous inspection have been largely addressed and clear plans are in place to promote the future development of the home. Quality monitoring systems are in place to ensure that service users, their representatives and other stakeholders in the service have a meaningful input into the development of the home. There are regular staff and resident meetings held providing alternative forums for people to share their views about the service. A range of records were examined in relation to health and safety issues. These records have been reorganised and archived where appropriate. All required records and service checks were in place including PAT tests, Gas safety certificates, Legionella tests on the water supply and periodical checks on the electrical wiring and installations. There is an up to date fire risk assessment and fire drills are being carried out on a regular basis. It was noted that some of the weekly and monthly in-house checks on fire safety systems have not been routinely completed. This issue was highlighted with the manager who has put systems in place to ensure that this will be carried out more consistently in the future. Refer to recommendation 5. Woodbridge House DS0000068213.V359575.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 X 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 26 No 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 YA35 Regulation Requirement Timescale for action 01/04/08 2. YA37 18(1)(a)(c) To develop staff training ensuring that all mandatory training is up to date and instruction in issues specific to people who use the service. 9(1)(2) The manager needs to progress through the registration process with the Commission for Social Care Inspection. 01/04/08 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. 2. 3. 4. Refer to Standard YA1 YA6 YA9 YA34 Good Practice Recommendations To update the statement of purpose and service user guide to reflect management changes. To continue to develop individual service user plans with regard to person-centred planning and development of independent living skills where appropriate. To further develop risk management processes including information to support the system of scoring rating levels of risk. To ensure recruitment records provide a full employment history and any gaps in employment are identified and DS0000068213.V359575.R01.S.doc Version 5.2 Page 27 Woodbridge House 5. YA42 accounted for. To ensure fire safety records are maintained and kept up to date. Woodbridge House DS0000068213.V359575.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: 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 Woodbridge House DS0000068213.V359575.R01.S.doc Version 5.2 Page 29 - 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. 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