Care Home: 19 Chilgrove Road

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What the care home does well From observing staff and residents it was clear that residents were happy living at the home and that staff and residents got on well together. Care plans were person centred and provided good information for staff on the support that was required and they informed staff how residents wanted this support to be given. Residents are given every opportunity to make their own decisions and they are offered choice in all aspects of their life. Staff are on hand to offer support when required. The residents are supported to participate in appropriate activities and are encouraged and supported to be involved as much as possible in the day to day running of the home and staff provides care and support to enable residents to live an independent lifestyle as much as possible. The routines in the home promote residents independence and they are encouraged to do as much as possible for themselves. The home has clear policies on equality and diversity and all residents` personal lifestyles are respected while personal image and dignity are maintained. The home has a dedicated and stable staff team and staff have been supported to obtain recognised qualifications and over 90% of the care staff employed by the home has either achieved or is working towards National Vocational Qualifications. They are committed to their role and work well together as a team. The home has an effective training programme and staff said that the home provides training in all areas and this enables them to carry out their job effectively. What has improved since the last inspection? Since the last inspection the home has improved the communication screening tool used to help staff understand residents wishes. The home has purchased a bigger television screen for the lounge which is digital, to offer more choice of preferred programmes. The home has purchased appropriate garden furniture and BBQ, plants and has had the outside front garden tidied and changed including the removal of a tree to ensure more natural day light is filtered into the home. What the care home could do better: There were no areas identified as needing improvement on this occasion. CARE HOME ADULTS 18-65 19 Chilgrove Road Drayton Portsmouth Hampshire PO6 2ER Lead Inspector Mick Gough Unannounced Inspection 6th August 2008 09:30 19 Chilgrove Road DS0000067318.V368919.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 19 Chilgrove Road DS0000067318.V368919.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. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Chilgrove Road Address Drayton Portsmouth Hampshire PO6 2ER 023 92 210602 023 92 210602 annemitchell3@nhs.net www.hantspt.nhs.uk Hampshire Partnership NHS Trust 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) Mrs Ann Mitchell Care Home 4 Category(ies) of Learning disability (0) registration, with number of places 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category 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 category: 2. Learning disability - LD The maximum number of service users who can be accommodated is: 4 12th September 2006 Date of last inspection Brief Description of the Service: 19 Chilgrove Road is a registered care home providing care and accommodation for up to four younger adults (aged 18 to 65 years) with learning disabilities. The home is formed of two residential houses to make one detached home at the end of a cul de sac. There are small front, side and rear gardens as well as off road parking. The home provides four single bedrooms of good proportions, two with en-suite facilities on the first floor and two without en suite facilities on the ground floor. Mrs Ann Mitchell manages the home. Fees at the home average £1,615 per week but this depends on the type and level of support required. Full details of current fess are available from the home. 19 Chilgrove Road DS0000067318.V368919.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 3 star. This means the people who use this service experience EXCELLENT quality outcomes. This report details the evaluation of the quality of the service provided at 19 chilgrove road and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out in November 2006. The inspection took into account; the previous key inspection report and the last annual service review which was carried out in December 2007 when comment cards were sent out to staff and residents at the home. Included in the inspection was an unannounced site visit to the home, which took place on the 6 August 2008. Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and users of the service. It was possible to meet all of the residents, however due to the nature of their learning disability it was not possible to obtain their views on how the home was meeting their needs. We did speak with 2 members of staff and the homes manager who assisted the inspector throughout the visit. The home is registered to provide support for 4 residents and at the time of the inspection there were 4 people living at the home. What the service does well: From observing staff and residents it was clear that residents were happy living at the home and that staff and residents got on well together. Care plans were person centred and provided good information for staff on the support that was required and they informed staff how residents wanted this support to be given. Residents are given every opportunity to make their own decisions and they are offered choice in all aspects of their life. Staff are on hand to offer support when required. The residents are supported to participate in appropriate activities and are encouraged and supported to be involved as much as possible in the day to day running of the home and staff provides care and support to enable residents to live an independent lifestyle as much as possible. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 6 The routines in the home promote residents independence and they are encouraged to do as much as possible for themselves. The home has clear policies on equality and diversity and all residents’ personal lifestyles are respected while personal image and dignity are maintained. The home has a dedicated and stable staff team and staff have been supported to obtain recognised qualifications and over 90 of the care staff employed by the home has either achieved or is working towards National Vocational Qualifications. They are committed to their role and work well together as a team. The home has an effective training programme and staff said that the home provides training in all areas and this enables them to carry out their job effectively. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 19 Chilgrove Road DS0000067318.V368919.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 19 Chilgrove Road DS0000067318.V368919.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service can be confidents that their needs would be fully assessed before they move into the home. EVIDENCE: Last inspection found that all residents in the home had lived together for between nine and fifteen years. There have not been any new admissions to the home and all assessments have been audited previously and no issues have been raised. The homes completed AQAA told us that the home provides copies of the homes terms and conditions in an accessible format and that there is a policy and procedure to follow with regards to any prospective new residents. The manager told us that introductory visits to the home would be arranged so that both the home and potential new resident can be confident that the individuals needs can be met. We looked at the homes service user guide and this gave any new residents the information they would need to enable them to make an informed decision on whether they wanted to move into the home. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The assessed needs and personal goals of residents are reflected in an individual plan of care and people who use the service are supported to make decision about their lives with assistance given by staff. Residents are supported to take responsible risks and this allows them to live an independent lifestyle as much as possible. EVIDENCE: Care and support plans were seen for 2 residents and these were comprehensive documents and were clear and easy to follow. Care plans were kept in each individuals bedroom and they gave clear information on individual, problems and needs and included information on daily routines, general health, sleep patterns, eating and drinking, likes and dislikes, skin care, hair care, personal care and there was a detailed communication screening tool in place. The communication tool provided staff with good information on how best to communicate with residents, all of whom had limited or no verbal communication skills. The communication tool had sensory information including taste and smells and gave staff good information 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 10 on individual’s non-verbal communication such as body language, facial expression, gestures and eye contact. There was a dictionary of how individuals communicated and showed staff how individuals expressed their likes and preferences such as pointing and smiling. It also showed how residents expressed their dislikes such as shouting or screaming. The communication tool explained what the individual resident does, what this means and provided information on how staff should respond. Care plans also had detailed support plans, which identified needs, gave information on desired outcomes and provided an action plan to achieve this. One plan for skills development gave step-by-step guidance for a resident to make herself a hot drink and this provided a consistent approach by staff. Care plans gave good information on personal preferences and personal image and these were evidenced in resident’s individual rooms. The AQAA stated that care plans were agreed with residents and were reviewed and updated regularly and this was confirmed by recording in the care plans seen. Care plans were reviewed every two months and the reviews provided an evaluation of how the care plan was working and also detailed any changes that were required. Daily recording was clear and provided good evidence of care delivery. Residents are supported to make decisions about their day-to-day lives and staff were observed interacting with residents and taking their views into account. Care plans and recording gave good information on how staff involved residents in decision making. Positive responses to choices offered included, smiling, laughing, pointing or eye contact. Negative responses would be walking away, screaming, refusing to comply or crying. One care plan said if the resident wanted to go out she would go to the door, if she wanted to be alone she would take herself to her room and if she wanted to change channel on the TV she would give the remote control to a member of staff. During the visit we observed staff offering residents choice and their decisions were respected. Care plans looked at contained risk assessments and these gave details of the assumed risk, the level of risk and also details of the risk. They detailed control measures to minimise the risk and they gave staff good information on any support that was required. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 11 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 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in appropriate activities and they have opportunities for personal development and are encouraged and supported to be part of the local community where they engage in appropriate leisure activities. The homes visiting policy supports residents to maintain family links and their rights are respected. Residents are offered support to plan their own menu are provided with a balanced diet in pleasant surroundings. EVIDENCE: The homes completed AQAA told us that residents are supported to be involved in a variety of activities of their choice and that individual plans were in place, which clearly promote independence, positive risk taking and choice. This was confirmed by the activities plans for each resident. The manager had colour coded each resident so that on the staff rota individual staff were identified to support residents with different activities. Outside activities included: swimming, bowling, walks, trips to cafes, shopping and meals out. Activities in the home included: puzzles, games, hairdressing, manicures, 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 12 cooking, music and videos and on the day of the visit one member of staff came on shift to support a resident to go out into Portsmouth to shop for her holiday and have lunch. All residents have additional activity programmes; one resident goes to a day service 2 days per week. One resident attends a support group 1 day a week and two residents go to another support group 2 half days per week. These provide additional activities where no staff input is required and we were told that residents enjoy these activities. Two residents at the home have befrienders who were arranged through social services and they visit regularly, one takes a resident out into the local community while the other supports a resident with activities in the home. The home has transport available for residents and there is a charge of 43p per mile for residents who use the homes transport for personal use. However the home has also supported residents to obtain taxi tokens from the local council to enable them to have as much independence as possible. Residents are supported and involved in planning holiday/ short breaks etc and one resident is looking to go away for a weekend in September and another is looking at going away for 10 days to Florida. Normal support for residents while on holiday is provided by the home but residents need to pay for any additional support residents may need while they are on holiday. The home supports residents to maintain contacts with family and friends and residents exchange greeting cards and speak to relatives on the phone and some relatives visit the home. The home has a clear visiting policy and visitors are always welcome and we were informed that staff would respect residents wishes on who they wish or do not wish to see. Daily routines in the home promote residents independence as much as possible and they are encouraged to participate in day-to-day routines in the home. During the visit staff were observed interacting with residents and they got on well together, staff used residents preferred form of address and those residents we saw appeared happy at the home. Staff were seen to knock on residents doors before entering and involved residents in all aspect of the day to day running of the home, residents were asked their views on what they wanted to do. Resident’s rooms reflected their individual personalities and the manager told us that residents could be involved as much or as little as they wanted. Residents have access to all areas of the home and there were no restrictions. Menus at the home are made up with resident’s involvement. The home has a menu pack made up by a dietician and these are colour coded, so as long as residents choose meals from different coloured sections then this ensures a balanced diet. Breakfast is normally a choice of cereals, toast or cooked items, lunch is normally a snack type meal and the main meal of the day is in the evening. A picture board with the menu for the evening meal is displayed in the kitchen and a record of all food consumed is kept. The manager told us that the menu is flexible to allow for meals out and take-a ways. Residents go 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 13 out with staff to buy the weekly shopping and they are also encouraged to help as much as possible with meals, snacks and drinks. Meals are normally taken in the dining room but residents can eat elsewhere if they wish. On the day of the visit we observed staff supporting residents with their lunch and this was unhurried and provided the support required. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are set out in an individual plan of care and residents have access to all relevant health care professionals and their health care needs are met. Residents are protected by the homes policies and procedures regarding medication. EVIDENCE: Personal support is offered in private and all of the residents are female. All permanent staff at the home are female but some of the bank staff are male. The home has a policy on cross gender care and resident’s wishes are respected. No male staff work at the home unless supported by a female colleague. One of the residents is able to be actively involved in her personal care but requires some staff support. Another resident is able to carry out some personal care tasks but needs staff to supervise and assist. Two residents require full staff support with all their personal care needs. All support needed is detailed in care plans and support is offered flexibly to suit residents needs. Residents are all registered at a local GP surgery, however may have different GP’s. Dental checks are obtained through a local health centre and sight tests 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 15 are obtained from local opticians. District nurses are available from the GP surgery and the home has the support of a dietician through GP referral. Support is available from the local learning disability team if required and other healthcare professionals are available through GP referral. Resident’s folders contained medical notes and appointment records and these provided evidence that resident’s health needs are monitored and met. Only two residents at the home have regular prescribed medication and a local pharmacist provides this to residents in a monitored dose system. Residents medication is stored in a locked drawer in the residents own rooms, however none of the residents are able to self medicate. Staff support residents with their medication and all staff have completed training in medication administration. One set of medication records was seen and these were clear and up to date. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure, which includes timescales for the process and residents can be confident that their views would be listened to and acted upon, any complaints are logged and responded to appropriately. The homes policies and procedures help to protect residents from any form of abuse. EVIDENCE: The homes completed AQAA told us that there had been no complaints since the last visit to the home and this was confirmed on the day of the visit. The home has a clear and accessible complaints procedure and this was in a format suitable for the residents at the home. Staff members spoken to were aware of the complaints procedure and the manager told us that she would assist and support any resident who wanted to make a complaint. The home has a copy of the Hampshire Adult Protection procedure and has a whistle blowing policy. Staff training records showed that staff receive training with regard to adult protection and POVA as part of their induction, there is also annual training in Safeguarding. The manager and staff members spoken to confirmed that they had received training and were aware of their responsibilities in this area. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment and the home is clean and hygienic and free from offensive odours. EVIDENCE: The home is a large and spacious and offers a good standard of accommodation. The home is tastefully decorated through out and furnished with good quality furniture and furnishings. Residents can choose where to spend their time and were observed to use the communal areas and also spend time in their rooms. There is a large communal lounge/dining room with a large wide screen TV where residents can relax. The kitchen was spacious and residents were supported to make drinks and snacks. One resident was keen to show us her room and this had been tastefully decorated to her own choice. All bedrooms had been personalised and reflected the individual’s personality. We were told that residents had been consulted about the decoration of the communal areas. There is a small enclosed garden with a sitting area with table and chairs and residents can choose to spend their time where they wish. All areas of the home were clean and tidy and we were told 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 18 that residents are encouraged to keep their own rooms clean and tidy and are supported by staff to do this. There is a small utility room, which has separate facilities for laundering clothing, and this is equipped with an industrial washing machine with sluice facility and an industrial tumble drier. Staff carry out laundry duties and there are systems in place for washing any soiled items. Residents and staff are provided with gloves and aprons and the home has policies and procedures on infection control and staff receive training in this area. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Competent, qualified and appropriately trained staff in sufficient numbers support residents and meet their needs. The homes recruitment policy and practice protect residents. EVIDENCE: The homes AQAA told us that the home employs nine permanent care staff and of these nine, seven have achieved NVQ2 or above and the manager confirmed this at the visit. We looked at the homes staff rota and this showed us that there is a minimum of 2 staff members on duty between 0700 – 2000 and from 2000 to 0700 there is one staff member on duty who is able to sleep between 1200 and 0600. The night staff member is backed up by an on call system and someone is available to come to the home to provide additional support if required. The staff rota allowed for flexible shifts to enable staff to support residents out in the community and additional staff are provided to facilitate activities and appointments. On the day of the visit an extra staff member came in to support a resident to go out into the community. The manager told us that she has a stable staff team who are reliable and flexible to meet resident’s needs. The manager told us that at present the staffing 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 20 levels were sufficient but that she would keep staffing levels under review as residents needs changed. The homes AQAA told us that the home has a robust recruitment procedure and we looked at the staff files for 2 staff members, both files contained application form, refs x 2, CRB/POVA, photo, passport and birth certificate. The organisation has a human resources department who assist in the recruitment of new staff and those staff spoken with told us that their recruitment was thorough. The home has a low staff turn over and there have been no new staff members employed in the past 12 months The organisation that runs the home has a training co-ordinator who provides training for all staff employed at the homes. Staff undertake induction training in line with “skills for care” and the induction is carried out over 5 consecutive days away from the home. Mandatory training is carried out in; moving and handling, fire safety, adult protection, medication, first aid, health and safety, food hygiene and infection control. Additional training is also made available to meet the needs of residents and this includes; learning disability, person centred planning, Strategies for Crisis Intervention and Prevention (SCIP) and managing challenging behaviour and communication. The manager told us that training needs are discussed as supervision and also at staff personal development planning, she told us that the organisation would support any training that would benefit the residents. Staff members spoken with confirmed that they had received a good induction and said that there was regular training provided at the home. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home and the views of residents and other interested parties are sought on how the home is meeting needs. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The homes completed AQAA told us that the Registered Manager has completed NQV4 in Care, the Registered Managers Award and NVQ4 in Management. We spoke with the manager who confirmed that she has these qualifications and she has been managing the home since it opened some four years ago and was previously the manager of another service. She told us that she regularly updates her skills through regular training. During the visit the manager was able to answer any questions asked of her and all records and documents were up to date and readily available. The manager works well with her team and the residents, and she operates an open door policy. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 22 The provider carries out regular regulation 26 visits to the home in accordance with the regulations and reports of these visits were available at the home. There are regular staff meetings each month and residents meetings are held quarterly. The organisation sends out annually, questionnaires to resident’s staff and other stakeholders to seek their views on how the service is operating. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for gas safety, fire alarms systems and equipment, private electrical equipment and fixed wiring. These are organised by the owners of the building who are a housing association and the manager has monthly meeting with a housing officer to discuss any issues of maintenance. There is an in date fire risk assessment for the building and regular health and safety monitoring takes place. 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 4 X 3 X X 3 X 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 19 Chilgrove Road DS0000067318.V368919.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone 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. 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