Care Home: 86 Harvey Road

What the care home does well The home deals with a number of diverse care needs and ensures to offer a very personalised service to meet the needs of those using the service. Staff show dedication and a real commitment to ensure that all those using the service, however diverse their needs may be, receive an individual personcentred package of care which meets their needs appropriately. The home is committed to providing staff with ongoing training, to ensure they have the relevant knowledge and skills to address their clients diverse needs and to allow for their own personal development. The homes policies and procedures around the recruitment and selection of staff are robust and serve to protect service users health and welfare. Users of the service are involved in the recruitment and selection process to ensure their opinions are taken into account when selecting any new staff. What has improved since the last inspection? Since the last inspection, carpets have been replaced in the lounge, a number of rooms have been redecorated and a new television and sofa for the lounge has been obtained along with a new computer with broadband access. Care plans have been reviewed and worked upon to ensure that all documents within these plans interrelate. The home has been re-accredited with investors in people award and has recently been awarded further accreditation with C.A.R.F. (Commission on Accreditation of Rehabilitation Facilities) an internationally recognised body. What the care home could do better: Review the notice board within the home to ensure that information displayed on the board is easily accessible. Provide each user of the service with their own personal copy of the recently produced complaints procedure which is in pictorial format. Ensure that where guidelines have been produced with service users and healthcare professionals, these be documented held in the service users care plansappropriately. CARE HOME ADULTS 18-65 86 Harvey Road Aylesbury Buckinghamshire HP21 9PL Lead Inspector Jane Handscombe Unannounced Inspection 14 and 15th August 2008 10:30 th 86 Harvey Road DS0000023066.V370515.R02.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 86 Harvey Road DS0000023066.V370515.R02.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. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 86 Harvey Road Address Aylesbury Buckinghamshire HP21 9PL 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) 01296 399341 kh@birt.co.uk The Disabilities Trust Mrs Christine Wood Care Home 3 Category(ies) of Physical disability (0) registration, with number of places 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Physical disability (PD). The maximum number of service users to be accommodated is 3. Date of last inspection 14th August 2006 Brief Description of the Service: 86 Harvey Road is a registered care home for three adults providing personal care and accommodation. The home is a satellite of Kent House but has its own registration. Harvey Road maintains some administrative support and the registered manager spends, on average two days a week at the home. The home is supported by a staff team of whom the core has been in post for some time. It is run by The Brain Injuries Rehabilitation Trust. The home has three bedrooms and comfortable communal areas and is situated in a residential street close to local shops and a hospital. Public transport is easily accessible. The current scale of weekly charge ranges from is £1220.72 to £1371.17. 86 Harvey Road DS0000023066.V370515.R02.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 was an unannounced key inspection, which took place over 2 days. The visit took place on the 14th and 15th August 2008. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The home was currently providing care and support to 3 service users with no vacancies available. All three of these users were sent questionnaires in order to ascertain their views upon the care they receive. Likewise surveys were forwarded to four permanent staff, two of whom responded and five healthcare professionals. Any further completed surveys we receive will however be considered as part of CSCI’s ongoing regulatory responsibilities for registered services. The CSCI Inspecting for Better Lives (IBL) involves us requiring the service to complete an Annual Quality Assurance Assessment (AQAA), which enables them to evaluate the quality of their service and forward to ourselves when asked. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process Results of this inspection report are derived from feedback gained from the service users, discussions with staff during the visit and responses to questionnaires sent out prior to this visit, viewing client’s records held within the service, viewing policies and procedures, staff personnel files, general observation throughout the visit, along with information provided to us within the AQAA and any other information that CSCI has received about the service in order to gain an understanding of how the service meet the service users’ needs, and impact upon their lives. We looked at how well the home was meeting the key standards set by the government and have in this report made judgments about the standard of the service. What the service does well: The home deals with a number of diverse care needs and ensures to offer a very personalised service to meet the needs of those using the service. Staff show dedication and a real commitment to ensure that all those using the 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 6 service, however diverse their needs may be, receive an individual personcentred package of care which meets their needs appropriately. The home is committed to providing staff with ongoing training, to ensure they have the relevant knowledge and skills to address their clients diverse needs and to allow for their own personal development. The homes policies and procedures around the recruitment and selection of staff are robust and serve to protect service users health and welfare. Users of the service are involved in the recruitment and selection process to ensure their opinions are taken into account when selecting any new staff. What has improved since the last inspection? What they could do better: Review the notice board within the home to ensure that information displayed on the board is easily accessible. Provide each user of the service with their own personal copy of the recently produced complaints procedure which is in pictorial format. Ensure that where guidelines have been produced with service users and healthcare professionals, these be documented held in the service users care plansappropriately. 86 Harvey Road DS0000023066.V370515.R02.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. 86 Harvey Road DS0000023066.V370515.R02.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 86 Harvey Road DS0000023066.V370515.R02.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, 4 and 5 Quality in this outcome area is excellent. Any prospective service users and all current service users are provided with a service users guide providing them with detailed information about the service in a format suitable to their needs. Prospective users of the service undergo an assessment of and are invited to spend some time at the home to ensure that both parties are confident that their needs can be met appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since there have been no new admissions to the home, we discussed the admission procedure and it was ascertained that a full assessment needs would be undertaken prior to a place being offered. In addition to a full assessment of needs, the person would be invited to spend days, overnight visits and weekend stays to enable them to gain a feel of the home and to ensure that all parties are confident their needs would be met appropriately at Harvey Road. Whilst viewing service users files there was evidence to highlight that visits ranging from day visits, overnight and weekend had been arranged to enable the service user to gain a ‘feel’ of the home prior to admission. Information about the home and the services that are offered is provided to both prospective and current service users in the form of a service users’ 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 10 guide, in a format suitable to their individual needs. All three service users confirmed to us us that they received enough information about the home before they moved in so that they could decide if it was the right place for them Whilst case tracking those who presently live at the home, it was noted that whilst they had been provided with a service users guide, it needed updating to reflect the new contact details of the Commission for Social Care Inspection. On the second day of our visit, it was ascertained that the manager had picked up on this omission and had dealt with it that very day to ensure that those using the service had up to date information. People using the service are all provided with a written contract and statement of terms and conditions of occupancy. Key workers discuss contracts and the service user’s guide with clients regularly at key sessions. There is a very real commitment to ensure that all those using the service, however diverse their needs may be, receive a person-centred package of care and support taking into account their individual preferences and goals to meet their needs appropriately. 86 Harvey Road DS0000023066.V370515.R02.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 and 9 Quality in this outcome area is good. All service users have an individualised plan of care and support detailing their assessed needs and personal goals and how these needs and goals are to be met. Service users are enabled to make decisions about their lives and are supported to take risks in all aspects of their daily lives promoting their independence and choice. This judgement has been made using available evidence including a visit to this service EVIDENCE: During the inspection the inspector viewed a sample of care plans and found them to be individualised and contain appropriate detailed information on the users individual needs and preferences and how these needs are to be addressed. Care plans are drawn up and reviewed on an ongoing basis 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 12 depending on a persons’ needs, health and support. Examples were seen of where people’s care plans had been updated to reflect their changing needs and support. In addition, there was documentation within the service users files to evidence that people’s needs were also reviewed through the local authority purchaser’s own review system. All reviews are undertaken with the involvement of the service user themselves together with family/representatives and other relevant health and social care professionals. The care plans viewed and conversations with staff confirmed that peoples cultural and individual preferences were understood by everyone and form an integral part of the care and support they are offered. The care planning system also includes a process for identifying and recording risks and hazards that people may experience. Thorough risk assessments were found to be contained within the care and support plans detailing any risks present and how these risks are to be minimised whilst promoting users choices and independence. Examples were seen where the staff team had worked with specialist healthcare providers to identify risk situations and how the persons behaviour may challenge them. Together they had developed ways to support people that minimises those risks so enabling them to take part in activities that they enjoy and to ensure they maintain their mental and emotional health and well being. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. People using the service are supported and encouraged to participate in activities and establish routines that they value and enjoy and meals are provided according to their preferences.. Service users are encouraged and supported to remain in contact with their families, which they enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People’s care plans were found to reflect their social and leisure interests, cultural activities, daily routines, family contacts and information regarding nutritional needs. On the morning that this visit took place, all users of the service were enjoying a breakfast out in the local community due to building work being undertaken in the home. Upon their return we spent some time with them discussing the 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 14 support and assistance they receive at the home. Through these discussions and from documentation within each persons file, it was ascertained that they are supported and assisted to undertake opportunities which allows for their personal development where required. People using the service are encouraged to engage in activities that they enjoy both within and outside of the home. One user of the service informed us of how he has been assisted to attend college to study mathematics and was looking forward to recommencing after the college break, whilst two further service users discussed their work placements; one of whose work placement involved walking dogs at a local boarding kennels and another who helps out at a local coffee shop. One service user explained how they were supported to maintain contact with family members how he is looking forward to travelling up north to visit his family. Whilst viewing the service users files, it was noted that one indicated that an assessment had been undertaken to ensure the service users ability to undertake a specific activity in the community and that guidelines were produced, however these were not contained within the particular service users file. Upon discussion it was ascertained that these had been archived. The manager agreed to ensure that the guidelines be retrieved and placed within the service users care plan. The staff team ensure educational and vocational needs are met. Each service user has a programme of personal activities of daily living and activities of which they choose to enjoy in the local community according to their own interests and hobbies. Their own bedrooms contain personal memorabilia and items to reflect these. Receipts of expenditure showed that service users use the local shops for clothes shopping, leisure activities and buying items such as toiletries and magazines. Residents are supported and encouraged to take responsibility for keeping their rooms clean and tidy and participating in the general tidiness of the home and to maintain their own skills. Service users contribute to the weekly menu planning. Whilst there was no one requiring special meals on cultural grounds at the time of this inspection, we were informed that these could be arranged if necessary. People using the service have recently enjoyed a barbeque and buffet to which family members, friends, neighbours and healthcare professionals were invited which was well attended and enjoyed by all. Likewise a family day was held at the organisations ‘sister’ home to which the people living at Harvey Road were invited and enjoyed. Service users can choose whom they see and can see visitors in their own rooms, in private, if they wish. There are no restrictions about family and friends visiting. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Service users are offered personal, physical and emotional support in the ways they require, ensuring that their care needs and health requirements are met and their well-being safeguarded. Medication is well managed, ensuring that service users receive the medicines they require to keep them healthy and well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained important information about individual personal support needs and how these need to be met. Staff spoken with demonstrated a good understanding of care needs and promoting service users’ independence and were effective in their key working roles. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 16 Service users have the disability equipment they require and risk assessments are in place regarding potential issues in the safe delivery of their care. Medical appointments are documented in care plan folders and showed that service users are supported to attend routine and specialist appointments. Medication is securely stored at the home and all required policies and procedures are in place. A monitored dose system is used with good support reported from the supplying pharmacy. Records showed that all staff who administer medication have received appropriate training and their competencies assessed. Medication entering and leaving the home is recorded and the medication administration charts were found to be completed accurately. The home does not hold any stocks of controlled drugs and authorisation had been obtained from doctors regarding use of homely remedies. No users of the service self medicate and all have signed a consent form indicating their wishes that staff support them in administering medication, however there are policies and procedures in place to enable people to retain the responsibility for their medication within a risk management process. There are protocols in place to govern the actions that staff should take if a resident refused medication and staff informed us that medication was never administered covertly. Weekly medication audits are undertaken. Healthcare professionals tell us that individuals needs are always met and that the service always seeks advice and acts upon it to manage and improve individuals’ healthcare needs. Comments received from the healthcare professionals include ‘all round care of patients is excellent’, they ‘produce individual care plans reflecting how well they know the client’ 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. The home has policies and procedures in place to respond to people’s concerns and to protect them from harm. People using the service are aware of how to make any complaints and feel comfortable that they would be listened to and appropriate actions would be taken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear complaints policy and procedure in place to address any concerns or complaints that people using the service may have, which sets out clear time frames for action. The procedure is provided in written format and has since the last inspection been produced in pictorial format to meet the varying needs of those using the service. Whilst each user of the service have a written copy in their file, the pictorial format was placed on a noticeboard within the home, however this was not in clear view due to numerous notices on the board and it was suggested that a personal copy be provided to each service user. The manager agreed to review the noticeboard and ensure each service user be provided with their own personal copy. An independent advocate regularly visits the home enabling users of the service to discuss any personal concerns in confidence and provide assistance and support in voicing any concerns/complaints they may have if required. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 18 Completed questionnaires sent out to service users prior to this visit tells us that they are confident about how to make a complaint and that if they had any concerns felt these would taken seriously and acted upon. No complainant has contacted either the service or the Commission with information concerning a complaint made to the service since the last inspection. There are policies and procedures in place to guide the manager and staff on how to respond to any suspicion of abuse, which are in line with the local Multi Agency procedures. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff member’s responsibility to ‘whistle blow’ on any poor practice or concerns that come to their attention. There have been no adult protection/safeguarding issues since the last inspection 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a clean, homely environment that is appropriate to the specific needs of the service users who live there. It is well-maintained and those using the service informed us that the home is always fresh and clean. All service users have their own bedrooms and share a lounge/dining room, kitchen, bathroom, shower room, laundry room and gardens which are safe, comfortable and adapted to the needs of those living there. The bedrooms are decorated and furnished to service users own personal tastes containing their own possessions. Service users have access to safe, well maintained gardens and outdoor tables and chairs. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 20 The service continues to upgrade the environment to ensure comfort and meet the needs of the people living there. Since the last inspection, carpets have been replaced in the lounge, a number of rooms have been redecorated and a new television and sofa for the lounge has been obtained along with a new computer with broadband access. Service users were consulted with and actively involved in the choosing of these new items. On the day of our visit, building work was taking place to provide for patio doors to allow for more light into the communal lounge and dining room and provide for better access to the garden and the home’s laundry facilities. Hand washing procedures are in place to prevent the spread of cross infection. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. The home is staffed in accordance with the needs of the service users and staff receive the appropriate training to meet their needs. A thorough recruitment procedure is followed to ensure, as far as is possible, the health, safety and well being of the residents in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes policies and procedures around the recruitment and selection of staff are robust and serve to protect service users health and welfare. Face to face interviews are undertaken, references sought and all the necessary checks are undertaken to ensure prospective staff’s suitability to work with vulnerable adults within the care field. Users of the service are involved in the recruitment and selection process to ensure their opinions are taken into account when selecting any new staff. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 22 All new staff, including any agency staff, are provided with an induction period and undergo all the necessary training to ensure they have the skills and knowledge to undertake their roles competently. Staff tell us that they are being provided with training that is relevant to their role, helps them to understand and meet the individual needs of those using the service and keeps them up to date with new ways of working. One member of staff spoken to during this visit informed us that training can be organised to further staffs knowledge in areas in which they feel would be of benefit and gave an example in which he/she felt training in dealing with death and bereavement would be of benefit, particularly in supporting people who experience bereavement in their own lives. He/she told us that the request was followed up and all staff were provided with such training. Observations of the interactions between staff and residents indicated that staff clearly understood the individual needs of those using the service and showed skill in communicating with them effectively. Staff were seen to spend one-to-one time with individuals as well as interacting with them in a group. Staff training is recorded in individual staff files and those viewed demonstrated the home’s commitment to staff development and training. All staff members have attained the National Vocational Qualifications (NVQ) in care, two of whom have gained level 2 and a further two hold level 3. 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is registered with the Commission and has completed the registered manager’s award. She is supportive of the staff team and visits the home on a weekly basis leaving the day- to- day management of the service to the team leader. Service users and staff spoke in complimentary terms about her management ability and the support she gives. The AQAA (Annual Quality Assurance Assessment), was returned to us in good time and had been completed to a high standard with details of improvements 86 Harvey Road DS0000023066.V370515.R02.S.doc Version 5.2 Page 24 made in all areas of care practice and detailed areas in which they plan to make improvements. The home has systems in place to ensure that clients and stakeholders views are obtained. People who use the service are involved in decision making; one to one weekly meetings are held with their key workers and monthly service user meetings are held to enable those using the service to be involved in any decisions relating to the service and to air any views that they may have. Monthly audits relating to health and safety and staff’s practice are undertaken. There is an annual and development plan, which is based on a systematic cycle of planning, reviewing and reflecting outcomes for clients. The home is accredited with investors in people and has recently been awarded further accreditation with C.A.R.F. (Commission on Accreditation of Rehabilitation Facilities) an internationally recognised body. The manager and the staff team are committed to promoting equality and diversity in the service and meeting service users individual needs. There have been regular monitoring visits undertaken by the provider with reports of these visits held within the home, all of which were made available to the inspector during the inspection. The home has a health and safety policy statement and provides training and equipment for staff. Safety checks relating to fire safety and infectious diseases are regularly carried out. The fire records indicated that the fire panel is checked weekly and service users participate in the weekly fire drills. 86 Harvey Road DS0000023066.V370515.R02.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 4 2 3 3 x 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 4 x 86 Harvey Road DS0000023066.V370515.R02.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 YA16 Regulation 15 Requirement The registered manager must ensure that where guidelines have been produced with service users and healthcare professionals, these be held in the service users care plans. Timescale for action 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. 1 Refer to Standard YA22 Good Practice Recommendations Review the notice board to ensure that that information displayed on the board is easily accessible and provide each user of the service with their own personal copy of the recently produced complaints procedure which is in pictorial format. 86 Harvey Road DS0000023066.V370515.R02.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. 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