Care Home: 25 Beacon Close

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What the care home does well The home is well managed. It has a good organisational structure. This means all staff are clear about their roles and responsibilities. The home supports the service users to make informed choices and to lead active and fulfilling lives. The home uses Person Centred Active Support (PCAS) philosophies to involve the service users in all aspects of life in the home. The service users are treated with a great deal of respect. Their privacy and dignity are preserved and the home actively promotes their health and wellbeing. There are comprehensive care plans that promote individualised health and personal care for the service users. The service users participate in a wide range of activities and make full use of local community facilities. The home has a strong philosophy of equality of opportunity, fairness and consistency of treatment for service users and staff. Staff are carefully vetted and well trained. Relatives and supporters say that they are "absolutely marvellous" and show great patience and care. Staff are commended for the way they support the service users and their commitment to improve the lives of the service users. There is a very pleasant and welcoming environment. The accommodation is well maintained and homely. What has improved since the last inspection? What the care home could do better: The home meets the standards of care for younger adults well but it would further improve the lives of the service users if they had more communal space. A conservatory would mean that there would be a lot more communal space and give more privacy for visitors. The home should try to find a better place to store documentation that is currently in the lounge. This would give the room a more homely feel. CARE HOME ADULTS 18-65 25 Beacon Close 25 Beacon Close Gillingham Kent ME8 9AP Lead Inspector Wendy Mills Unannounced Inspection 27th November 2007 10:00 25 Beacon Close DS0000064376.V353135.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 25 Beacon Close DS0000064376.V353135.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. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 25 Beacon Close Address 25 Beacon Close Gillingham Kent ME8 9AP 01634 370581 01634 370581 janeshoults@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Ltd 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) Jane Shoults Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: 25, Beacon Close is a residential home providing care and support for three people with learning disabilities. The service is part of a group of homes managed by the Avenues Trust. The registered manager for this service is Mrs Jane Shoults. The home is a detached property situated at the end of a quiet cul-de-sac in Rainham, Kent. There is a bus route nearby and the centre of Rainham is about fifteen minutes walk away. The accommodation is arranged over two floors. On the ground floor there is a small lounge/diner, one service user’s bedroom, a kitchen, laundry room, toilet with wash hand basin and a garage that is used for storage. On the first floor there are two further service users’ bedrooms. There is a third, smaller bedroom that is used as a staff sleepover room and office. There is a bathroom and toilet on this floor. Outside there are gardens to the front and rear. The rear garden is of a good size and is safe and enclosed. There is off road parking to front of the property. In addition it is possible to park on the road near the home without any restrictions. The home is located in a residential area and is convenient to Rainham town centre, which has a number of amenities including a doctors’ surgery, library, post office, public houses and churches. The fees were given as £1,104 per week at the time of this visit. Further information can be obtained directly from the Registered Manager of the home. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced. It formed part of the inspection process of the Commission for Social Care Inspection (CSCI) under the Regulations of the Care Standards Act 2000. This report has been compiled using information gained during this visit and information supplied prior to the visit from a variety of sources including the home’s Annual Quality Assurance Assessment (AQAA) that is required by the CSCI. During the visit in-depth discussion was held with the registered manager, Mrs Jane Shoults. Time was spent with the service users, interacting with them and making both direct and indirect observations. Relatives and staff were spoken to both in private and during a tour of the home. Other relatives and visiting health care professionals were contacted by telephone to seek their views. A tour of the home was made and documentation, including staff files and care plans was examined. Both direct and indirect observation was used throughout the visit. The home meets the National Minimum Standards very well. The supporters of the service users say that they believe the residents are well cared for and that they lead fulfilling and meaningful lives. The requirements from the last inspection have been met. No requirements were placed following this visit. The service users, staff and registered manager are thanked for the welcome they gave and their help throughout this visit. Relatives and other supporters of the service users are thanked for taking the time to give their views. What the service does well: The home is well managed. It has a good organisational structure. This means all staff are clear about their roles and responsibilities. The home supports the service users to make informed choices and to lead active and fulfilling lives. The home uses Person Centred Active Support (PCAS) philosophies to involve the service users in all aspects of life in the home. The service users are treated with a great deal of respect. Their privacy and dignity are preserved and the home actively promotes their health and wellbeing. There are comprehensive care plans that promote individualised health and personal care for the service users. The service users participate in a wide range of activities and make full use of local community facilities. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 6 The home has a strong philosophy of equality of opportunity, fairness and consistency of treatment for service users and staff. Staff are carefully vetted and well trained. Relatives and supporters say that they are “absolutely marvellous” and show great patience and care. Staff are commended for the way they support the service users and their commitment to improve the lives of the service users. There is a very pleasant and welcoming environment. The accommodation is well maintained and homely. 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. 25 Beacon Close DS0000064376.V353135.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 25 Beacon Close DS0000064376.V353135.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the residents, their relatives and supporters, with the information they need. Appropriate pre-admission assessments are made. This ensures that only those residents who are suited to the home and whose needs can be met are admitted to the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide. There are easy to read versions of both these documents. Relatives say that the home keeps them informed of any changes and takes their views into consideration. No new service users have been admitted to the home since the last inspection. There are sound policies and procedures in place in respect of preadmission assessments and trail periods. There are regular reviews and any changing needs of the service users are recorded in the care plans. 25 Beacon Close DS0000064376.V353135.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 home supports the service users to make appropriate and informed choices. This helps them become more independent. EVIDENCE: The home has introduced Person Centred Active Support (PCAS). This means that they try to involve the service users in choices about every aspect of their lives. They use “Opportunity sessions” to help the service users make informed choices. One of the service users had taken part in a session on the morning of this visit. Relatives said that they were very impressed with the way the home helped the service users to expand their horizons. One said, “He can choose to do all sorts of things – things that I’d never thought possible”. Staff said that the service users are able to make a lot of choices about the way they live their lives. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 10 The care plans are in good order and show that all aspects of the service users’ lives are considered. Direct and indirect observation showed that the service users were able to choose how they spent their time but were encouraged to participate in the everyday life of the home rather than to do nothing. One relative said that the service users are able to make choices that at one time had just not seemed possible. Another said, “I am amazed at the amount of choice they have. I wouldn’t have thought it possible some years ago, this is the best place he has ever lived in and I’m so pleased that he is happy and settled”. The registered manager explained that the “Opportunity sessions”, are aimed at widening the experience of the service users. Goals are agreed and ways of achieving these goals are worked out. For example, one service user indicated that he would like to have more friends. The home has arranged for him to attend social clubs and to have friends visit for a meal. Good records are kept of the progress that each service user makes. The service users are encouraged to take appropriate risks, and safety guidelines are set out for their various activities. 25 Beacon Close DS0000064376.V353135.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. The service users lead busy and interesting lives and are able to choose how they spend their time. This means that they can lead fulfilling lives and be as independent as possible. EVIDENCE: The staff said that they encourage the service users to make decisions and choices. For example, there are photographs of a variety of foods so that the service users can participate in menu planning and choose what they want to eat. None of the service users manages his own money totally but they do visit the bank and take as much part as possible in the transactions for their personal monies. A tag system is used in the home to ensure the security and safe accounting of these monies. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 12 The service users participate well in local community life. They use the local sports centre and education centre. They visit the shops, local pubs and other leisure facilities. They also go horse riding and on outings. Records of activities, including trips out and holidays, are kept for each resident and appropriate risk assessments are in place. Records show that there has been a significant increase in community activities since the last inspection. The service users are encouraged to take part in every aspect of life in the home. On the day of this visit one helped make drinks for the visitors and another helped with the washing up. Staff were observed to encourage participation throughout the day. In the summer the home held a party to enable the service users to catch up with both old and new friends. One of the service users loves to spend time in the garden. The home have helped him make an herb garden as he loves to touch and smell the different plants. This has helped him improve his understanding of plants that are safe to touch and those that are not. The routines at the home have become even more flexible throughout the last year. This means that the service users can be supported to stay out later in the evenings if they wish. The home supports the service users to maintain family and friendship links. Relatives said that they could visit when they like and are always made very welcome when they visit. The home can provide transport and staff to support the service users when they make visits to their families if necessary. A monthly newsletter is produced for those families who are unable to visit. The service users have made good progress in the way they make choices and they way they participate in the running of the home since the introduction of Person Centred Active Support (PCAS). They have been able to broaden their experiences. For example, from contact with family, it was discovered that one of the service users used to like playing football. The home then arranged fro him to take part in a five-aside game at the local leisure centre. Although this was not a great success, they realised that he now prefers to watch football, rather than play it. They have arranged for him to go and watch a game. Nutrition in the home is well managed. The home promotes healthy eating. The Trust recently carried out a healthy lifestyles audit. This audit included a close look at nutrition. The results were very positive. Staff said that they try to promote healthy food choices whenever possible. Meals are flexible and the service users are encouraged to be as independent as possible in all aspects of nutrition, from understanding healthy eating to planning and preparing meals. They can help themselves to drinks and snacks and are supported to make meals. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 13 On the day of this visit there was plenty of good quality, fresh produce in the home. The pantry and fridges were well stocked. Conversation with staff showed that they understand food and nutritional needs. Special diets can be catered for if necessary. 25 Beacon Close DS0000064376.V353135.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 good. This judgement has been made using available evidence including a visit to this service. The home promotes the health and well-being of the service users and protects their privacy. This means that they can enjoy as healthy a lifestyle as possible and can be confident that their dignity will be respected. EVIDENCE: The personal care needs and the way personal care is to be managed is set out clearly in the care plans. Staff said that they try to involve the service users, their relatives and supporters as much as possible in this process. There are clear policies and procedures in respect of support with personal care. Examination of care plans and tracking to health and social care appointments showed that specialist advice is sought appropriately and acted upon. The service users are registered with local GPs. There is good evidence to show that health care professionals such as Occupational therapists, physiotherapists, speech and language therapists, specialist nurses and psychologists have been consulted and their advice followed. Staff said that they maintain very good relationships with visiting professionals. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 15 The home has demonstrated that they can meet the changing needs of the service users as they face the aging process. Staff are good at spotting signs of pain, for example, when a service user may be showing signs of arthritis. They have also managed changing behaviours well. The manager and deputy manager have already attended specialist training to help them cope with the situation. All staff are now booked to attend the same course. Relatives said they were very impressed with the patience and skill that the staff have shown in coping with some unexpected and behaviours. Nutrition in the home is well managed. There are healthy eating initiatives and there is continuous monitoring of food intake, weight and other nutritional indicators such as skin condition and general health. Medication is well managed. No service user self-medicates. Medicines are stored appropriately in a locked cupboard. There are no controlled drugs stored in the home but there is a locked facility for their storage should the need arise. Records are in good order. The Medicines Administration Record (MAR) was examined and found to be in good order. All staff administering medication have been trained to do so. The home has introduced medicines checks that now take place three times each day. Since the last inspection there was one reported medication concern. The wrong dose of medication had been inserted in the Nomad box of one service user. This was not the fault of the home but it was staff at the home who discovered the error. Since this time they have contacted the pharmacy to discuss the issue. The staff are commended for their diligence in spotting the problem and dealing with it promptly and professionally. 25 Beacon Close DS0000064376.V353135.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. The home responds appropriately to concerns and complaints and has sound systems in place for the protection of vulnerable adults. EVIDENCE: There are sound policies and procedures for the handling of complaints and concerns. The manager and the company are quick to respond to any concerns raised with them. Staff have been trained in the Protection of Vulnerable Adults (POVA) and are clear about their responsibility to report any concerns they may have in the respect of the way the service users are treated. Those spoken to were clear about their responsibilities to report concerns under the whistle-blowing policy. They said that there is a strong staff team and that no form of abuse would be tolerated. Staff said that they can talk to the manager. They said that she listens to any ideas they may have. Communication in the home is good. There are regular service user meetings, one-to-one staff supervision sessions and staff meetings. Relatives said that they had no complaints at all. One said, “We’ve no complaints, in fact, I don’t think they could do any better than they do”. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 17 Relatives said that they know how to make a formal complaint but cannot envisage having to use this process. They said that they are kept informed and consulted appropriately. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is tidy, well maintained and clean. This gives the service users a pleasant and homely place in which to enjoy their lives. EVIDENCE: There is a warm and welcoming atmosphere in the home. It is tidy, wellmaintained and very clean. Universal infection control procedures and environmental risk assessments are in place. A service manager visits the home regularly. There have been a number of environmental improvements since the last inspection. These include a redecoration programme, new furniture in the lounge, new flooring in the kitchen and a new bath seat in the upstairs bathroom. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 19 The service users were involved in all aspects of the improvements from being supported to choose colour schemes for the redecoration to helping to choose the furniture. All the requirements placed at the last inspection, in respect of the environment, have been met. It is good that the service users were able to take so much part in these improvements. Further redecoration is planed and more new furniture is to be purchased for one of the bedrooms. The rear garden of the home is well kept, safe and enclosed. Herbs have been planted to encourage one of the service users to improve his sensory ability by using touch, taste and smell to distinguish between plants. The lounge/diner at Beacon Close is not very spacious. Whilst this room provides a cosy space for the service users it does mean that it is difficult for them to have any privacy when they have visitors. If it were possible to build a conservatory onto the rear aspect of this room, it would give the service users more space, a more stimulating place to sit and more privacy. The home should investigate the possibility of this improvement to the home. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training and funded staffing levels are good. However, unforeseen circumstances have led to a shortage of permanent staff. This had impacted, to some degree, on continuity of care. Recruitment practices are sound. This means that the service users are supported by a carefully vetted staff team. EVIDENCE: The home has a registered manager and a deputy manager. Staff say that they have clear roles and responsibilities. Relatives and supporters spoke very highly of the staff. They said that they are kind, caring and enthusiastic. They said that they communicate well and that they always feel welcome in the home. One said, “The staff are lovely, I have seen so much improvement since Avenues have taken over the home”. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 21 The home has to use some bank staff at present. Avenues has its own bank staff and ensures that staff working at the home are familiar with the service users and their needs. Conversation with staff showed that they are very committed to their work in the home. They showed great enthusiasm for the way in which they are now able to support the service users in broadening their experiences and taking more control over their lives. They said that there is a strong staff team that puts the needs of the service users first. Staff said that they are offered very good training opportunities within the Trust. Avenues, the Trust that runs the home, is currently developing an education and training division as part of its services. This division is called “The Avenues Academy”. It is in the process of developing an extensive programme that includes both statutory training, such as infection control, and specialist education, for example, management of epilepsy and diabetes. Examination of staff files showed that all staff are maintaining their continuing education and statutory training. Records of training undertaken are very well maintained and monitored. There is a structured system for the induction of new staff. All new staff must complete a workbook within their first six months of employment. There is a six-month probationary period for all new staff. The Trust has strict and robust recruitment policies and procedures. The Criminal Records Bureau (CRB) and references are stored at the company’s head office but copies of tracking forms are held in the home. These forms include the CRB numbers. They were inspected and found to be in order. The company has always made it clear that original records will be made available if requested. These records were not requested at this visit. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the service users. Their needs are identified and met and their health and well-being is promoted. The views of their supporters and staff are listened to and acted upon. EVIDENCE: The registered manager, Jane Shoults, is well qualified for the role of registered manager. She has recently achieved the National Vocational Qualification at level four (NVQ IV) in management and care. She holds the NVQ assessors award (D32/33) and is soon to complete the Registered Managers’ Award (RMA). She has consistently demonstrated a strong ethos of 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 23 openness, honestly and a commitment to continuous improvement of the service. Relatives, staff and supporters of the service users all say that there is more direction and sense of purpose Avenues took over the home. They say she is approachable and listens to their concerns. The home operates a key worker system that identifies a staff member who will work directly with a service user on a one to one basis. This means that the key worker can ensure constancy of care and communication, and if necessary, advocate on behalf of the service user. There trust has sound quality assurance systems in place. These include regular checks by the service manager, a system to ensure that the views of the service users are heard. The Trust runs a group called, “Our Say”, which works with service users to take their views into consideration. One of the service users from beacon Close attends this group and receives payment from the trust for his input. During this visit the registered manager was able to readily produce all documentation that was requested. Records show that regular fire and health and safety checks are made. Fridge temperatures are monitored and other hazards identified and dealt with. No health and safety hazards were noted during a tour of the home. The service manager make regular visits to the home on behalf of the company. Regular reports are submitted to the CSCI in accordance with Regulation 26 of the Care Standards Act. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 4 12 3 13 4 14 3 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 3 X X 3 X 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. 1 Refer to Standard YA28 Good Practice Recommendations The Trust should consider the possibility of providing a conservatory or similar, to give additional communal space. This would give the service users more privacy when they have visitors and more room in which to move around. 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 26 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 25 Beacon Close DS0000064376.V353135.R01.S.doc Version 5.2 Page 27 - 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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