Care Home: 267 Hersham Road

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What the care home does well The home has a pleasant atmosphere and staff are friendly and approachable. The registered manager and staff run the home in the best interests of service users and there is an emphasis on service user inclusion. Information has been provided for service users so that they can be enabled to make more choices. Staff are well trained and supported and they were observed to have a good relationship with service users and to be knowledgeable about their needs. Care plans are well maintained and the information in them is very comprehensive and up to date. Health and personal care needs are well met and any concerns are referred to health or social care professionals and acted upon. Record keeping and documentation overall is of a very good standard. The home is clean and well maintained. What has improved since the last inspection? All the requirements made at the last inspection have been met. The manager has become registered and since being in post has brought about positive changes to the home and developed the service. There has been an overhaul of a large amount of the homes` recording and systems that has brought about positive changes for service users and staff. At the time of the last inspection the home had undergone some changes in it`s management, it is has now stabilised with the result that the service has improved. Service users have been encouraged to become more involved in the running of the home and their views are acted upon. Systems for gaining the views of others such as relatives and care managers have been developed. There has been some redecoration and refurbishment, the garden is more pleasant for service users to use and there are plans for further environmental improvements. Information such as that about the home, service users` weekly activities and the complaints process has been put into pictures and symbols so that service users can access it better and feel they are more included. The activities available for each person have been reviewed and there are individual planners in place. Care plans have been brought up to date and the information in them reviewed and made easier to find. Staff files have also been updated and contain all the necessary information and up to date organisational pro formas. What the care home could do better: The home is beginning to work towards introducing more person centred care plans, and ways in which service users can be more involved in their care plans and the process of drawing them up, this must be progressed. All staff working at the home must attend a POVA training course. CARE HOME ADULTS 18-65 267 Hersham Road Walton-on-Thames Surrey KT12 5PZ Lead Inspector Debbie Sullivan Unannounced Inspection 2nd September 2008 09:30 267 Hersham Road DS0000013470.V371502.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 267 Hersham Road DS0000013470.V371502.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. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 267 Hersham Road Address Walton-on-Thames Surrey KT12 5PZ 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) 01932 226125 01932 226125 hersham@regard.co.uk The Regard Partnership Ltd Raymond Alan Booker Care Home 6 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places 267 Hersham Road DS0000013470.V371502.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 categories: Learning disability (LD) 2. Physical disability (PD) The maximum number of service users to be accommodated is 6. Date of last inspection 25th July 2007 Brief Description of the Service: 267 Hersham Road is a care home providing residential care for up to six service users with mild to moderate learning disabilities, two of which may also have a physical disability. The home is detached and is situated in a residential area a short distance from Walton on Thames town centre and its facilities. The bedrooms are situated on two floors, two bedrooms are on the ground floor and four bedrooms are on the first floor. Bedrooms are personalised and homely. There is a bathroom on each floor. Service users have opportunities to participate in a variety of activities at home and in the community. The garden is of a good size, secluded and safe for the service users to enjoy. There is parking for three cars and the homes’ vehicle in the front of the building. The fees for the home range from £1,251.00 to £1,537.00. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over six hours. During the visit time was spent with service users, the registered manager, the locality manager, staff and a relative. The home was toured and the care plans of three service users were read. A range of the homes’ other documentation was inspected including medication records, staff records, policies and procedures and risk assessments. The AQAA (Annual quality Assurance Assessment Document) completed by the Registered Manager also provided information that has been used as part of this inspection, as has information provided in a small number of health professional and staff survey forms returned to the Commission. At the time if the visit the home had one service user vacancy. Staff and service users were friendly and very helpful in providing information during the visit. The quality rating for this service is 2 star. This means that people who use the service experience good quality outcomes. What the service does well: The home has a pleasant atmosphere and staff are friendly and approachable. The registered manager and staff run the home in the best interests of service users and there is an emphasis on service user inclusion. Information has been provided for service users so that they can be enabled to make more choices. Staff are well trained and supported and they were observed to have a good relationship with service users and to be knowledgeable about their needs. Care plans are well maintained and the information in them is very comprehensive and up to date. Health and personal care needs are well met and any concerns are referred to health or social care professionals and acted upon. Record keeping and documentation overall is of a very good standard. The home is clean and well maintained. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home is beginning to work towards introducing more person centred care plans, and ways in which service users can be more involved in their care plans and the process of drawing them up, this must be progressed. All staff working at the home must attend a POVA training course. 267 Hersham Road DS0000013470.V371502.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. 267 Hersham Road DS0000013470.V371502.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 267 Hersham Road DS0000013470.V371502.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 3 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the home is made available to potential future service users and their representatives. Needs are fully assessed before a place at the home is offered and prospective service users have opportunities to visit the home and spend time there before deciding to move in. EVIDENCE: There were five service users living at home when the visit took place. The manager said that there had been interest in the current vacancy and he was taking care to make sure that any future service users were compatible with those already living there. Any potential service user is assessed by the manager or locality manager and introduced to the service carefully. Introductions go at the service users pace and can include visits to the home and the opportunity to have an overnight or longer stay to try it out. The needs of the current service users were being well met. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 10 Information about the home is available in the service users guide that has been developed on a pictorial format as well as in text with photographs. There is an up to date statement of purpose, both documents are on display along with the last CSCI inspection report. 267 Hersham Road DS0000013470.V371502.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): 6,7,8 and 9 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are well maintained and reflect the needs and preferences of service users, they need to be made more accessible for service users. Importance is given to offering service users opportunities to be involved in the running of the house and to make decisions about their lives. EVIDENCE: Each service user has a comprehensive care plan, care plans have been separated into two folders one is dedicated to health information and the other is for individual and lifestyle information. The care plans of three service uses were read, all the information was up to date easy to find and clear about the service users likes and dislikes and 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 12 preferences. Sections on cultural, religious and communication needs were included and staff reading the plans would be provided with all the information and guidance they needed to meet needs satisfactorily. Where the service user had stated they preferred male or female staff to support them with personal care this was recorded and staff spoken with were aware of preferences. Needs were being regularly reviewed internally and with relatives and care managers, any changes were well recorded and documented. Risk assessments are in place. The care plans however are not yet very easy for service users to access or to be involved in. The manager and locality manager said they propose to introduce more accessible and person centred plans. Forms giving agreement that staff could administer medication had been signed by service users or noted their verbal permission and had pictures on. Service users are included in the daily life of the home and importance is given to offering them opportunities to give their views on it and to make personal decisions and choices. There are weekly residents meetings, six monthly surveys and keyworker meetings. Some service users have limited verbal communication; staff on duty knew the service users well and were able to communicate effectively with them to establish their choices. During the visit service users were encouraged to help with tasks such as shopping and getting ready for lunch and were offered choice of activity. One service user was being supported over decisions about their future and the possibility of moving to more independent living, they understood that this was to go at their own pace. 267 Hersham Road DS0000013470.V371502.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): 11,12,13,14,15,16 and 17 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to take part in a wide range of activities of their choice including activities that maintain and promote independence. Service users are supported to maintain contact with friends and relatives. Meals are varied and healthy and service users contribute to meal planning. EVIDENCE: Service users have opportunities to take part in a range of activities at home and in the community. The activities programme has been reviewed since the last inspection to include a wider range. Each person has a pictorial weekly activity planner that clearly shows what they are doing each day and activities are geared towards individual interests and abilities. New activities have been 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 14 introduced as a result of service user consultation. Activities include college, a drama group, bowling, swimming, going to the library, going out for lunch and arts and crafts. One service user said they were going to the drop in centre the next day and went out to lunch with a relative on the day of the inspection, another went shopping for personal items. Evening activities are available such as groups and bingo; the manager has taken some service users to bingo the previous evening. The home has a dedicated vehicle that is used to take service users out. At home service users are encouraged to help with domestic tasks, gardening and cooking. All the service users were going on holiday the following week, two to centre parks and three to Devon. One service user was having ongoing support at home from an occupational therapist so that they could develop their independence skills with a view to moving on from the service. Contact with friends and relatives is supported and there are no restrictions on visting, the relative present said they regularly visited and staff were seen to welcome them warmly when they arrived. Service users are offered keys to their rooms and their rights and privacy are respected. During the visit service users chose to spend time alone or with others and to take part in the daily routines and to chat with staff or to observe whilst being in others company. There is pictorial information on display about the right to vote. Service users are involved in menu planning and food shopping and their views on meals are recorded at residents meetings. The menu is healthy and varied and there is always choice available, the main daily meal is served in the evening. 267 Hersham Road DS0000013470.V371502.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are sensitively met and their privacy and dignity is respected. Service users are protected by the medication procedures in place. EVIDENCE: Personal and healthcare support needs are well documented in care plans. Preferences for the delivery of personal care are clearly recorded and gender preferences respected as far as possible. Service users vary in the amount of personal care support they need, some need support in all areas and those more able may just need some prompting or supervision. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 16 Routines are flexible and service users get up, get dressed and have breakfast when they choose. Service users are supported to attend medical appointments and the home has worked particularly closely with a specialist health team, other health professionals and social services over recent months regarding a service user whose changes in behaviour caused concern. The joint working has proved effective and behaviour management guidelines and a future plan for the service user has been drawn up with their agreement. Care plans showed that any health concerns are promptly addressed and a record is kept of any GP, dental or other health appointments. A service user had seen the continence nurse and another was assessed by an occupational therapist to see if any aids to mobility could be provided. Medication is properly stored and medication-recording sheets read were correctly completed, medication is only administered by staff trained to give it. 267 Hersham Road DS0000013470.V371502.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 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and others can feel confident that any concerns or complaints will be listened to and addressed. The home has policies and procedures in place to protect service users from harm. EVIDENCE: The home has a complaints procedure that has been made available for service users pictorially; it is on display on the wall near the office. No formal complaints had been made during the past year, the manager said concerns are dealt with before they become complaints. A relative visiting confirmed this and said they felt listened to. Some of the service users have limited communication; staff know them well and understand if they are not happy. One service user has an advocate to act on their behalf and another is on a waiting list for one, it was clear the home promotes advocacy if it is needed. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 18 There are safeguarding and whistle blowing procedures and a staff member said that staff are regularly reminded about them at team meetings. A copy of the Surrey multi agency safeguarding procedure is available in the home. There had been one safeguarding vulnerable adults alert made since the last inspection that had been fully investigated by social services, the outcome was that it was unfounded. Guidelines are in place for the management of any challenging behaviours so that other service users and staff are not put at risk. Staff are provided with POVA training, one member of night staff still needed to attend the course. Recruitment procedures are thorough and CRB checks are taken up. No employee at the home acts as appointee for any service user. Records are kept of financial transactions and each service user has a cash box with cash and bank books in. The amounts in the boxes were checked for two service users and were in order. The organisation has a corporate appointeeship arrangement for some service users. 267 Hersham Road DS0000013470.V371502.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): 24,25,27,28,29 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. . Service users live in a safe, clean and comfortable environment that is undergoing improvements. Individual bedrooms reflect personal interests and meet needs. EVIDENCE: Improvements have been made to the environment since the last inspection that had identified a number of areas where work was required; there are plans for more redecoration and refurbishment to take place. There has been some redecoration of communal areas and the garden has been tidied up. The manager said that new carpets are to be fitted in the bedrooms of four service users and the following week general maintenance 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 20 work and repainting of areas such as chipped paint on woodwork was to take place whilst service users were on holiday, this would minimise disruption for them. One service user was aware they were to have a carpet that matched their paintwork better and said they had chosen the colour for the paint. The office/sleeping room was to be improved as well. Kitchen units are to be replaced as they are looking a little worn and a new fridge was on order. Communal areas of the home are the open plan lounge/dining room and large hallway, two service users who are less mobile have their bedrooms downstairs the other bedrooms are upstairs. The home was clean and hygienic throughout and service users are supported to keep their rooms clean and tidy. All the occupied bedrooms were seen; each reflected the personal interests of the occupant. Personal items included photos; books, TV’s and cuddly toys one service user had a new music system, as they preferred this to television. There is a toilet and bathroom on each floor one bathroom had new flooring. During the day service users were moving freely around the communal areas and their rooms and making use of the lounge. There is equipment available for those who need it such as a bath seat and handrails and the garden is accessible via a path or ramp. The garden is well kept and attractive with garden furniture and ornaments, the weather was not good on the day of the inspection but the manager said the garden is well used when it is fine. 267 Hersham Road DS0000013470.V371502.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): 31,32,33,34,35 and 36 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A committed and confident staff team supports service users. Staff are well supported and recruitment procedures are thorough. EVIDENCE: There have been some staffing changes over the past year and some new staff had been recruited, the staff team is multi cultural and there was one vacancy for a senior staff member, the manager was interviewing for this post later in the day. Staff working at the home are knowledgeable about the needs of service users and some have been in post for some time. There were sufficient staff on duty during the visit, the two on duty in the morning were both bank staff although they only work at the home and had both been employed by the organisation for over a year. The manager said that it is extremely rare that agency staff are used. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 22 Staff on duty were cheerful, confident and approachable and there was a good rapport between them and the service users and with the manager. One sleeping and one waking member of staff are on duty at night. The organisations head office manages a good deal of the recruitment documentation and the home keeps a pro forma with information on recruitment information held at HO in the staff files. Files for three staff members were read; the proformas stated for example that the necessary checks and information such as references had been obtained. CRB checks are repeated three yearly as good practice. The manager follows up references by telephone if additional information or evidence of previous employment is needed. Staff files also contained supervision recording and training certificates, supervision takes place regularly. A member of staff spoken with felt well supported and said any issues could be brought to the manager in between supervisions. The home now has a new organisational training manager, a training matrix is in place and the manager and locality manager envisaged that training tracking would develop further. The matrix showed that staff receive core training and service specific topics are also offered such as dementia and epilepsy. All but one of the staff had had POVA training. Over fifty per cent of the staff have undertaken NVQ in care courses at level 2 or 3,three were waiting for their certificates. New staff have induction training and an annual appraisal system is being introduced. 267 Hersham Road DS0000013470.V371502.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): 37,38,39,40,41 and 42 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a friendly atmosphere and is run in the best interests of service users and staff. The views of service users and others are sought and robust internal quality assurance procedures are in place. EVIDENCE: The Registered Manager is now well established at the home and has brought about improvements and stability to the service since the last inspection. 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 24 The manager has gained the Registered Managers award and is undertaking their NVQ 4. The manager and staff have improved the service overall, examples are methods used for recording, care plans, staff files, pictorial information for service users, increased service user inclusion and the introduction of quality assurance surveys for service users, relatives and health and social care professionals. The service users survey is pictorial and all the forms were on display for use. A manager from another of the organisations homes undertakes the monthly regulation 26 visits; the manager of Hersham road had compiled an action plan responding to the issues raised in the visits. Staff spoken with said that the manager is approachable and a relative that the home was much better and staff were more of a team since he had arrived. The home has a friendly feel and staff and service users were welcome to come to speak to the manager in the office, there is an open door policy. Equipment is kept maintained at the relevant intervals and fire equipment is checked, fire evacuation practices take place regularly that involve service users and are recorded, a service user confirmed this. Investment has been made to improve the service and the manager and locality manager discussed plans for more work on the environment and on areas such as training. 267 Hersham Road DS0000013470.V371502.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 3 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 3 30 3 STAFFING Standard No Score 31 3 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 3 3 2 3 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 3 3 3 x 267 Hersham Road DS0000013470.V371502.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 YA6 Regulation 15(1)(2) Requirement Care plans must be presented in a format that is more accessible for service users and that enables them to be more involved in the content. All day and night care staff must attend POVA training. Timescale for action 31/12/08 2. YA35 18(1) 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI 267 Hersham Road DS0000013470.V371502.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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