Care Home: 87 Westbrook Avenue

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What the care home does well Each service user has their own individual plan, with pictures and photographs that make it meaningful for them. The care plan looks at everything about them and helps staff to make sure they can make choices and work towards achieving their wishes and aims for the future. Staff spend time with service users getting to know what they like and helping them to make choices. Staff are good at using various different methods of communication to suit individual needs. This enables them to plan opportunities for service users that are what they really want. Service users take part in a wide variety of activities. They have individual holidays, which they choose themselves. This makes sure their lives are fulfilling. The home has its own transport, which is adapted for wheelchair use, for the benefit of service users to access the wider community. Staff have the skills and confidence to support service users effectively. Staff expressed that they enjoy working at the home and that they are well trained to meet the needs of the people living there. The home is well run by a competent and effective management team. What has improved since the last inspection? The home has continued to develop the way it supports service users to live meaningful lives. It follows the principle of `person centred active support` and methods used by staff to really get to know the service users have resulted in them having more choice about everything they do. The home has continued to make sure the environment is safe and homely for service users. New patio doors have been fitted in the lounge, providing another fire exit route. A new fire door has been added between the lounge and dining room, and a new fire awareness panel has been put in the staff sleep-in room. This has improved fire safety for service users and staff. What the care home could do better: The home continues to provide a very good service. One area that they particularly need to look at is the laundry facility, to make sure that it is fit for purpose and has everything necessary to prevent the spread of infection in the home. This is important with regard to staff hand washing, as at present they are using a nearby bathroom for this that poses a risk of contaminating two door handles. Also it is difficult for service users to access, without having to go out of the front door and back through the garage doors to get into the laundry. This is problematic when the weather is bad and was raised at the last inspection as an area for future consideration. CARE HOME ADULTS 18-65 87 Westbrook Avenue 87 Westbrook Avenue Margate Kent CT9 5HB Lead Inspector Christine Grafton Unannounced Inspection 6th February 2008 13:30p 87 Westbrook Avenue DS0000023720.V358366.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 87 Westbrook Avenue DS0000023720.V358366.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. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 87 Westbrook Avenue Address 87 Westbrook Avenue Margate Kent CT9 5HB 01843 291751 F/P 01843 291751 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) glebe.house@theavenuestrust.co.uk The Avenues Trust Ltd Hayley Taylor Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2007 Brief Description of the Service: 87 Westbrook Avenue provides residential care for up to three people who require a high level of assistance because of their learning disabilities. The premises comprise of a detached bungalow with a large well-maintained garden, situated in a residential area in Margate. The home is within a short walking distance of local amenities such as the health centre, shops, churches, library and day centres. The service users healthcare needs are accessed within the community. The needs of the three service users are such that they all require assistance with transport, and the home has its own minibus. Staffing comprises a registered manager and support staff, with regular support from area and regional management. The home is owned by The Avenues Trust, which is a registered charity. The current fees are £2083.08 per week. However, this date is near the annual fee review date and there may be an increase from 1st April 2008 in line with inflation. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that people who use this service experience excellent quality outcomes. This report takes account of information received since the last inspection, including a visit to the home. An unannounced visit took place on 6th February 2008 between 13.30 hours and 17.40 hours. The visit included talking to the manager, staff, service users and observing interactions between service users and staff. We made observations of the home routines, activities and staff practices. Some records were looked at and we looked round the home. Information sent to us by the manager prior to the visit, in the form of the home’s annual quality assurance assessment, has been used and information from the previous inspection referred to. At the time of the visit there were three service users living at the home. The atmosphere in the home was welcoming and relaxed. What the service does well: Each service user has their own individual plan, with pictures and photographs that make it meaningful for them. The care plan looks at everything about them and helps staff to make sure they can make choices and work towards achieving their wishes and aims for the future. Staff spend time with service users getting to know what they like and helping them to make choices. Staff are good at using various different methods of communication to suit individual needs. This enables them to plan opportunities for service users that are what they really want. Service users take part in a wide variety of activities. They have individual holidays, which they choose themselves. This makes sure their lives are fulfilling. The home has its own transport, which is adapted for wheelchair use, for the benefit of service users to access the wider community. Staff have the skills and confidence to support service users effectively. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 6 Staff expressed that they enjoy working at the home and that they are well trained to meet the needs of the people living there. The home is well run by a competent and effective management team. 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. 87 Westbrook Avenue DS0000023720.V358366.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 87 Westbrook Avenue DS0000023720.V358366.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their individual aspirations and needs are assessed and will be met by the home. EVIDENCE: Each service user has their own copy of the service users’ guide, written in simple language, with pictures, to make it easy for them to understand. Although no new service users have moved into the home for about three years, all current service users have had their needs comprehensively assessed by The Avenues Trust. These assessments have been used to develop holistic care plans that provide staff with all the information they need when supporting service users in their daily lives. The home’s annual quality assurance assessment (AQAA) states that prospective service users are visited by the house manager and a full assessment of needs is carried out with the help of present carers and relatives. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 9 The Avenues Trust has a development manager to assist service users with moving into a new service, or moving from an existing service. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 10 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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from having holistic person centred plans, which have been put together with their involvement and take into account their assessed needs, wishes and aspirations. Service users can be confident that staff will support them in meeting their changing needs, making choices and decisions, and leading independant lifestyles. EVIDENCE: We looked at two service users’ files, spent time with the service users and spoke to the manager and staff about their needs. Care plans are ‘person centred’ and contain information around individual needs, preferences and choices. They include a holistic profile and a cultural 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 11 needs assessment, making sure that any issues relating to equality and diversity are addressed. The care plans are written in a highly personal way that shows the service user involvement. Information is presented in a positive and sensitive style that is easy to understand, written in simple language with pictures and symbols. The plans are regularly reviewed on an ongoing basis and formal reviews take place every six months. The home’s AQAA states that the home follows the principle of ‘person centred active support’. This has been developed to enable service users to gain more control over their lives, ensuring they have more choice in everyday tasks, more independence and more involvement in the community. A staff member described a good example of how an opportunity session had been used to help a service user make a choice of drink. The person cannot communicate verbally, so they were shown a container of hot chocolate and given the chance to smell it, next they were shown a strawberry milkshake and then a tea bag. The person had grabbed the hot chocolate and tea. When these two were offered again, the person chose the hot chocolate on two consecutive occasions. All of this had been documented in the care plan to make sure that this information is passed on to other staff. Various different methods of communication are used and these are recorded in the care plans. These might include use of pictures, symbols, objects of reference, or specify the facial expressions and gestures used to show likes and dislikes. The care plans contain very detailed guidelines for staff on how to communicate with each individual. This ensures that service users are supported to make choices and decisions. The use of these forms of communication was observed throughout the visit and used in a positive way by staff to enable the service users to make choices. The service users were seen to respond well to the methods of communication used and to participate in their chosen activities. Risks are assessed and strategies devised to support any risks identified. This means service users are not restricted but supported to take risks as part of an independent lifestyle. Service users’ behaviours were relaxed and staff were enthusiastic about their work in the home. This together with the verbal information provided by staff confirmed what was written in the care plans. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 12 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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home will be responsive to their culture, religion, age and disability. They will know that they will be supported to live fulfilling lifestyles, both within the home and in the wider community. They will be able to keep in touch with family and friends and have relationships with people that are important to them. They will benefit from having a healthy diet, with meals at times and in places that suit them. EVIDENCE: Staff showed us the weekly activity plans for each service user. These are pictorial and show a range of activities that are organised to suit service users’ individual preferences and abilities, both in the home and outside. On the day of the visit, one service user’s activities were music therapy in the morning and 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 13 aromatherapy in the afternoon. Staff said how much the service user enjoys these events and the person was clearly relaxed after their afternoon activity session. Other activities might include such things as assisting with household chores and attending day services arranged by The Avenues Trust, or the local social services day opportunities centre. With the introduction of person centred active support (PCAS) each service user has a regular individual opportunity session that aims to identify preferences and then develop goals to plan for future activities. The manager described an example that showed how a service user with diverse needs, relating to age and disability, had been enabled to become more involved in the household. Staff had used the sessions to find out what the person liked to do and by providing active support, the service user had been mixing better and their behaviour had improved. Care plans contain details of service users’ religious preferences, attendance at church services, visits to the library, cinema, local leisure centre, swimming pool, bowling centre and shopping centres. Service users are supported to go on individual holidays, which have included: one person going to Euro Disney, another going to a Centre Parc in Sussex and planned holidays to Dorset and Folkestone. All of these are supported by detailed risk assessments and management strategies, with appropriate staff support. Day trips are also arranged according to individual preference. Staff spoke with knowledge about the importance of service users being part of their local community. Evidence of this was supported in documentation seen. The home has formed good relationships with neighbours. The home has its own transport for the benefit of service users, which is used together with other forms of public transport to access the wider community. Staff spoke about use of a taxi service that can take people in wheelchairs. This is sometimes used in the evenings if service users want to go out. A care plan showed that a service user had achieved their goal of going on a train. The home’s AQAA states that service users are supported to maintain family links by ensuring they are always made to feel welcome, inviting them to parties and other house functions and sending newsletters. This was supported in the care plans seen and discussion with staff. Care plans contain an informative visual section entitled ‘People in my Life’. The AQAA states that the menus have been updated and the home focuses on a healthy lifestyle. The kitchen is spacious and suitable for service users to eat in, instead of the dining room, if they choose to on some occasions. There is plenty of room for them to take part in cooking tasks, using their wheelchairs. Service users’ files contain records of meals taken, and their likes and dislikes. 87 Westbrook Avenue DS0000023720.V358366.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from being given the personal support that ensures their physical and emotional needs are met and they can be confident that they will receive good health care. They are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service users’ plans contain holistic personal and health care assessments. These indicate their needs and choices with regard to personal care. There is a gender to gender policy and service users’ choice regarding this is recorded in their care plans. Wherever possible, rota planning allows mixed genders and skills on shift. Personal care needs are well recorded in the care plans and are kept under regular review. An in depth plan entitled: ‘how I like to be supported’, was seen in one service user’s file. This contained all the information needed to make sure they receive personal support in the way they prefer and want. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 15 Health records show that service users have regular appointments with routine and specialist health services. These include: involvement with the dietician, occupational therapist, speech & language therapist, physiotherapist and specialist nurses, such as the epilepsy nurse. Records show doctors visits, district nurse visits, hospital appointments, dental appointments, orthotic appointments (for special boots) and access to wheelchair clinics. Nutrition is closely monitored and monthly weight records are kept. Routine health screening is also evident in records seen, such as access to the Well Woman Clinic and Well Man Clinic. Medication storage and administration records were seen in discussion with the manager. Medication is stored securely and records are well maintained and up to date. There are good systems in place for ordering and receiving medication into the home. A record is kept of medication entering the home. The medication administration records (MAR) had been well recorded and there were no gaps. Guidelines are in place for the use of ‘when required’ medication. Staff attend medication training and are checked regularly for competence. 87 Westbrook Avenue DS0000023720.V358366.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be assured that any complaints will be looked into and acted upon and the home’s policies, procedures and practices will protect them from abuse. EVIDENCE: The home has a written and pictorial complaints procedure that is included in the service users’ guide. There is also an audio format that is kept in the office. The AQAA shows there have been no complaints in the past year. The manager stated in the home’s AQAA that part of the quality assurance monitoring includes gaining feedback from relatives and others involved in the service users’ care, including comments from day centre staff and external professionals. Service users have the opportunity to join The Trust’s ‘Our Say Team’ where they are supported to air their views about the service. All staff attend valuing diversity training and the manager has attended training on managing diversity. There are policies and procedures in place to address equality and diversity and safeguarding adults. The induction training for new staff makes sure they are aware of the complaints procedure and whistle blowing policy. They attend safeguarding adults training as part of The Trust’s mandatory training programme. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 17 The Avenues Trust employs a challenging behaviour support manager who provides training, advice and support to staff when dealing with challenging behaviour. 87 Westbrook Avenue DS0000023720.V358366.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, 26, 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from the comfortable, homely environment that suits their individual and collective needs. However, improvements need to be made to the laundry in order to maintain safe hygiene and protect service users and staff. EVIDENCE: The home is spacious, on one level and adapted to suit the needs of the service users, so that they can access all communal areas and their own bedrooms. At the time of the visit, the home was clean, bright and cheerful. The AQAA states that the home has maintenance reporting procedures that make sure repairs and redecoration are dealt with in a timely manner. Observations made during the visit confirmed this. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 19 Service users’ bedrooms are attractively decorated and comfortably furnished. They are very individual, with each personalised in an age and gender specific way that reflects the service user’s character. The home has environmental adaptations and equipment necessary to meet the individual needs of each service user. The home has a selection of handling aids, electronic beds, an Arjo bath and suitable safety systems, such as alarms. Communal areas are spacious and furnished so that there is plenty of room for service users to eat together in the dining room, move about in their wheelchairs, or relax in the lounge. Since the last inspection, new patio doors have been fitted in the lounge and a new fire door has been fitted between the lounge and dining room. The home has a good size garden, with ramped access for service users to use for activities in the warmer weather. The home has a current fire risk assessment on the premises and a pictorial fire procedure is displayed. Since the last inspection, a fire awareness panel has been put up in the staff sleep in room to improve safety at night. The clinical waste bin is located in the bathroom. It has a flip-top lid and it was discussed with the manager that a foot operated pedal bin would provide more protection against the spread of infection in the home. At the last inspection, a recommendation was made to look at how access to the laundry could be improved, so that service users can get to it from indoors, without having to go outside and use the external door. This is because internal access is restricted for people in wheelchairs, due to the narrow corridor and step. The manager said nothing had been done about this, as the current service users are not particularly interested in actually putting their washing in the machine. The laundry has a stone floor and painted brick walls with a corrugated roof. The manager stated that the roof has been repaired this year. She also confirmed that the floor and walls have been treated so that they are impervious. Although there is a liquid soap dispenser on the wall and paper towel dispenser, the sink was dry and badly stained. The manager said that in practice, staff wear gloves and go to the staff bathroom nearby to wash their hands, but this poses a risk of contaminating two door handles. Also, there is no bin. Therefore, service users could be placed at risk, as there is the potential for spread of infection. The manager agreed to ensure this is addressed by the end of May 2008. 87 Westbrook Avenue DS0000023720.V358366.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): 32, 34, 35 & 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from the well-trained, enthusiastic and supportive staff team at this home. The home’s recruitment procedures and training programme support service users and staff. EVIDENCE: There was three staff on duty, at the time of the visit, to support the three service users living at the home. Rotas seen indicate sufficient staffing numbers on duty to meet the service users’ needs. Rotas are planned to take account of individual activities. Staff are enthusiastic about their work at the home and committed to supporting service users in the best way possible. Staff have a good understanding of the service users they support. All staff complete a comprehensive induction and foundation training and go on to do their National Vocational Qualification (NVQ) Level 2 or above. Service specific training is 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 21 undertaken and annual refresher courses are completed. Any agency staff used, complete an induction. Two staff files were viewed and contained records showing that thorough checks had been completed, including two references, criminal records bureau (CRB) checks and protection of vulnerable adults register (POVA) checks, providing service users with appropriate safeguards. There is a stable staff team, with good retention rates. Staff are allocated as key workers for certain service users. This results in consistency of care, which benefits service users. Staff were observed supporting service users in a positive, consistent manner. Staff have regular recorded supervision meetings that cover key service user issues, staff issues and personal development. The manager said that observation of the staff member doing person centred support is being introduced as part of the supervision process. 87 Westbrook Avenue DS0000023720.V358366.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, 40, 41 & 42 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well run home that is led by a competent and experienced manager. They also benefit from the organisation’s self monitoring, review and development processes that make sure service users’ views are at the heart of any changes made. Service users’ health and safety is protected. 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has an NVQ level 4 in care, a Registered Manager Award and is an NVQ Assessor. At the time of the visit there was an acting senior support worker, but the post had been advertised along with a deputy manager post. Once these positions are filled there will be a full management team at the home. The manager spoke with knowledge and understanding of service users’ needs, the day-to-day operation of the home and of The Trust’s ethos and policies. Staff on duty said that the manager is approachable and supportive. They were also appreciative of the support offered by the organisation as a whole, saying that this is a good place to work. The manager carries out regular quality audits and sends reports to senior management. A service manager from The Trust visits the home unannounced each month, to monitor the quality of the service and identify any areas needing development, or improvement. The home has its own development plan, which ensures that the manager and organisation address issues and plan for the future. Quality assurance monitoring takes account of service users’ views, which are then considered in future plans. There are clear policies and procedures in place, with appropriate risk assessments and safety checks completed within the home. The home’s records are maintained to a high standard. Regular staff meetings are held. All of this protects service users and makes sure their best interests are promoted. The AQAA was well completed, with clear, relevant information that has been supported by the evidence seen at the visit. Information taken from the home’s AQAA, discussion with the manager, and a tour of the home, indicate that apart from the laundry issue previously referred to under the Environment section, health and safety practices are carried out to protect service users and staff. 87 Westbrook Avenue DS0000023720.V358366.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 x 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 x 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 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 4 4 4 4 3 x 87 Westbrook Avenue DS0000023720.V358366.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. 1 Standard YA30 Regulation 13(3) Requirement That the laundry room is fit for purpose and suitable arrangements are in place to prevent infection and the spread of infection in the home. To make sure there is a suitable hand washing facility for staff to wash their hands in the laundry room and to provide a waste bin. That the clinical waste bin is foot operated to reduce the risk of spread of infection in the home. Timescale for action 30/05/08 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 YA24 Good Practice Recommendations That the refurbishment of the laundry is included in the home’s business plan. That consideration is given to improving the access to the 87 Westbrook Avenue DS0000023720.V358366.R01.S.doc Version 5.2 Page 26 laundry so that it is more accessible for service users. 87 Westbrook Avenue DS0000023720.V358366.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. 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