Care Home: Cristos

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What the care home does well Residents benefit from the continued support of a team of staff who are committed to meeting their needs and who are enthusiastic about the services they provide. It was evident throughout the inspection that staff and management are flexible in their approach and make the most of the resources available to them. The home has systems in place to ensure that residents` care needs are met and that they have access to a range of appropriate professional practitioners. Medication is managed well. Residents have access to a range of social, educational and vocational activities. The home is a spacious property with a location that facilitates independence. Each resident has their own key to their bedroom and their space and privacy are fully respected. What has improved since the last inspection? Action has been taken to comply with the requirements of the last inspection. As such residents are now protected by improved infection control practices in the home including a refurbished laundry and protective clothing for staff to wear in the kitchen. Recruitment practices are also now more robust with the Registered Manager ensuring that residents are supported by appropriate people through the obtaining of at least two written references prior to a new member of staff commencing employment. Since the last inspection, a new bedroom on the lower ground floor has been registered, which provides this individual with a spacious bedroom and their own dedicated bathroom. CARE HOME ADULTS 18-65 Cristos 27 Medina Villas Hove East Sussex BN3 2RN Lead Inspector Lucy Green Unannounced Inspection 30th June 2008 10:00 Cristos DS0000014194.V366622.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 Cristos DS0000014194.V366622.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. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cristos Address 27 Medina Villas Hove East Sussex BN3 2RN 01273 773717 01273 726076 joyskatulla@hotmail.com www.uknursinghomes.org/cristos Mrs Joy L Skatulla Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Joy L Skatulla Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is eleven (11) Service users must be aged forty-five (45) years or over on admission Only service users with learning disabilities may be accommodated Date of last inspection 19th September 2006 Brief Description of the Service: Cristos is a private family owned residential home registered for ten adults with learning disabilities who are over forty- five years on admission. The home is a substantial detached Edwardian house in a residential road, close to the main shopping area of Hove and the seafront. The property is leased by the Registered Provider/Manager. Resident accommodation is provided on four floors with seven single and two double bedrooms. One recently converted bedroom on the lower ground floor has its own dedicated bathroom with a walk-in shower facility. Those people who share a room have expressed a positive wish to do so. There is a passenger lift which provides access to the floors above ground level, although this was awaiting repair at the time of inspection. Communal space consists of a sitting/dining room and small foyer that also serves as a smoking area. There are three communal bathrooms and toilets. Access to both the front and rear of the home is via steps and the layout of the home therefore makes it unsuitable for service users who have restricted mobility. More detailed information about the services provided at Cristos, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents, along with the latest CSCI inspection reports are on available on request from the home. Cristos DS0000014194.V366622.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 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Cristos are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, a review of the home’s Annual Quality Assurance Assessment and an unannounced site visit which lasted four hours and forty minutes on Monday 30th June 2008 between the hours of 10am and 2:40pm. The site visit included a partial tour of the premises and an examination of some care, medication and staffing records. The Inspector observed the interaction between staff and residents as they planned activities and prepared and served the lunchtime meal. Throughout the inspection process, the Inspector met and spoke with seven of the eleven people living at the home. Time was also spent individually with the Registered Manager, Deputy Manager and the support worker on duty was interviewed in private. What the service does well: Residents benefit from the continued support of a team of staff who are committed to meeting their needs and who are enthusiastic about the services they provide. It was evident throughout the inspection that staff and management are flexible in their approach and make the most of the resources available to them. The home has systems in place to ensure that residents’ care needs are met and that they have access to a range of appropriate professional practitioners. Medication is managed well. Residents have access to a range of social, educational and vocational activities. The home is a spacious property with a location that facilitates independence. Each resident has their own key to their bedroom and their space and privacy are fully respected. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The required actions highlighted as a result of this inspection are primarily focused on the service ensuring it remains up to date with changes to government legislation and guidance. As Cristos has been judged to be providing good outcomes to the people who live there, it will not be inspected as frequently as it has been in the past. In order to continue as a good service, the Registered Provider/Manager must ensure that the home continues to develop and provide evidence of the ongoing improvements that are made. The care planning system is required to be developed to include comprehensive health action plans for residents that are in line with the ‘Valuing People’ recommendations. These should also lead to a revision of the homely remedy policy that must adopt a more person centred approach, rather than a generic statement across the service. The home must purchase a controlled drugs cupboard that complies with the specifications outlined in the Misuse of Drugs Act 1971 to ensure that the home can safely store any such medicines that may come into the home in the future. Whilst there have not been any significant complaints made about the quality of services at Cristos, the home should introduce a dedicated book for the formal recording of any comments received about the service. The ongoing maintenance and refurbishment of the home must also continue, with immediate attention being paid to completing the works on the first floor bathroom and the repair of the passenger lift. Cristos DS0000014194.V366622.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. Cristos DS0000014194.V366622.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 Cristos DS0000014194.V366622.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from an admission process that ensures their individual needs and aspirations are appropriately assessed prior to moving into the home. Current residents enjoy living with a group of people they know and who they are compatible with. EVIDENCE: There has been one person who has moved into Cristos since the last inspection in September 2006. The person originally came to the home on a respite basis, but with the agreement of all parties the stay has been continued and the resident is currently on a trial for a permanent placement. The assessment information for this individual was viewed and provided evidence that a thorough assessment process had been undertaken prior to the person coming to live at Cristos. Documentation showed that information had been gathered from a variety of sources, including the gathering of reports and feedback from a range of professionals and relatives that provides a holistic view of needs. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 10 The Registered Manager confirmed that either she or her Deputy Manager undertake pre-admission assessments and also highlighted that the information gathered by the home during respite stays or trial periods plays a crucial role in the developing of care plans. The majority of the people living at Cristos have been there many years and as such the Registered Manager confirmed that compatibility with existing residents is key in the assessment of any prospective resident. Conversation with residents and staff and the observation of interaction between residents at the time of the inspection indicated that residents benefit from living with other people who have similar needs, interests and expectations. As such the atmosphere in the home was found to be relaxed and friendly. Cristos DS0000014194.V366622.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans include up to date information and guidelines to support individuals and identify the goals in place to maintain and develop skills. Residents benefit from support that they are consulted about and which enables them to take managed risks. EVIDENCE: Through discussion with staff and observation of their practices, it was demonstrated that they have good relationships with the people they support and an understanding of their needs. The Inspector tracked the care for three residents, which included a partial examination of their care plans, activity schedules and a discussion with the Registered Manager. The Inspectors also met with all three residents during the course of the inspection. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 12 The system of care planning has been updated since the last inspection and as such they are now accessible and user-friendly documents. One staff member now has designated responsibility for maintaining care plans and has fully taken on board the issues raised at the previous inspection about the way information is updated. Care plans are now in a typed format which makes the process of review and amending easier and clearer. There was also evidence that residents are now included in discussions about their support needs and have each signed their care plans to indicate their agreement with the information contained. Care plans provide a good overview of support needs and the level guidance is reflective of the complexity of the individual. The majority of the people living at Cristos are independent with regards to their personal care and the staff support required is more coaching and prompting than actual physical support. For those that require a higher level of care, the guidelines in place are more detailed. A range of risk assessments were in place for the residents’ whose care was tracked. The home has a positive approach to risk taking and residents are supported to take risks to maximise their choice and independence. Each care plan viewed contained details of the short and long term goals that had been set for the individual. It was evident that the goals in place are both current and relevant to the person’s personal circumstances. Evidence gathered from documentation and observation of staff supporting residents during the inspection, highlights that the home provides a service where residents are encouraged and supported to lead independent lives. Cristos DS0000014194.V366622.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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the opportunities to access the local community and to participate in educational, social and meaningful activities. Residents are supported to maintain and develop relationships with other people and receive a range of balanced and wholesome food. EVIDENCE: Activity timetables identified that residents have access to a range of social and educational activities that are meaningful to them. The home does not have a dedicated vehicle to take people out, but the location of Cristos provides easy access to a range of community facilities and there are excellent public transport links. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 14 On the day of the inspection, seven of the residents were at home for part of the inspection, with one resident having been to work and another who had been shopping and returned for lunch. Four residents were out at day centres. Five residents were observed enjoying each others company in the lounge and were seen to be chatting happily whilst either reading a newspaper or doing word puzzles. Discussion with one resident provided information that he attends a work placement one day a week which he thoroughly enjoys. The individual went on to talk about he goes to work on the bus independently and really likes the freedom that allows. Another resident spoke about the clubs they attend and how much they enjoy the trips out, especially to the cinema. The Inspector was told by one person “I love it here as I can do what I like to do”. The home has a positive approach to enabling residents to maintain and develop relationships with other people. There was evidence in the daily diary books that the home supports residents to meet with and receive visits from their relatives and friends. Two residents told the Inspector that they had been a couple for many years and explained how supportive and respectful the home are to them. Meals at Cristos are prepared according to a three weekly rotating menu. The menu is drawn up in consultation with residents to reflect the meals they wish to have. The menu is also reflective of individual likes and dislikes and therefore on some days different meals are prepared for different residents. The Deputy Manager who has designated responsibility for menu planning confirmed that meals are flexible according to choice, activities and the weather. The menu displayed and record of food taken included a range of varied and well-balanced meals. The home was found to be well stocked with food and it was evident that meals are freshly prepared. Conversation with residents provided evidence that they are happy with the meals they receive. All spoken with expressed satisfaction with the food and comments such as “the food is good and you always get a choice” and “you get nice food here” were echoed by everyone who met with the Inspector. The Inspector observed the preparation and serving of the lunchtime meal. The majority of residents had pork pie and salad, although it was noted that some people chose variations of this and one individual had requested a pack lunch to have in his room. The food served was appetising and well presented. The lounge/dining room is arranged with two tables and for many residents mealtimes are a sociable occasions. For others who prefer to eat alone however, this too is respected and facilitated. Cristos DS0000014194.V366622.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported with their health and personal care needs in a professional and sensitive manner. Residents are protected by the systems in place to manage medication. EVIDENCE: Care plans provide documentary evidence that personal and healthcare needs are being met. It was evident that appropriate referrals are made to external professionals, including GP’s, dentists and opticians. There was evidence for the residents case tracked, that they are regularly weighed and records maintained The home has not currently introduced health action plans in line with Valuing People. Whilst care plans provide information about health care support, it is required that these action plans are introduced. Medication systems were assessed by way of a review of records, storage and discussion with the Deputy Manager. The medication policy was not inspected Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 16 on this occasion, although it was noticed that the home has a generic policy on homely remedies. It was highlighted that through the process of health action planning this policy should be replaced with person centred agreements with the General Practitioner and Pharmacist about what homely remedies each individual can take. The administration, recording and storage of medication were judged to be satisfactory, although the home is required to purchase an appropriate cupboard for the storage of controlled medication. Whilst the home does not currently hold any controlled medication, changes in legislation require all care homes to provide this facility. The Deputy Manager reported that staff undertake medication training with Brighton & Hove City Council and confirmed that no staff handle medication until they have successfully completed this and in-house training. Cristos DS0000014194.V366622.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the systems in place to listen to their views and safeguard them from harm. EVIDENCE: The home has a complaints procedure in place and an accessible copy is kept on display for residents’ and visitors to access. Neither the CSCI nor the home however have received any complaints about the service at Cristos since the last inspection. The home seeks to operate an open culture where issues are openly discussed and opinions shared. Positive interaction was observed between residents and staff during the inspection. Residents are encouraged to voice their opinions about the things they like and dislike. The home does not however have a formal complaints book. It is recommended that one be put in place so that all parties have a system for ensuring any complaints or concerns are appropriately recorded and responded to. The home has a number of systems in place to protect residents from abuse. New staff are employed subject to robust recruitment procedures and the necessary checks being undertaken. There are appropriate systems for supporting residents’ with their finances. The training list provided by the Registered Manager confirmed that all staff have received training in the safeguarding of vulnerable adults. There has been one safeguarding alert Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 18 made in respect of Cristos since the last inspection. The home had comprehensive records pertaining to this allegation and whilst strongly affirms that the allegation was unfounded has implemented the actions agreed. Cristos DS0000014194.V366622.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a safe and comfortable environment that meets their needs. The home will be further improved once the passenger lift has been repaired and other scheduled works have been completed. EVIDENCE: The Inspector undertook a partial tour of the home, which included the communal areas and six bedrooms. The remaining bedrooms were locked due to residents being out and therefore these rooms were not seen. Cristos is a spacious house that is laid out over four floors. The home has generally been decorated and furnished to a good standard, although the homeliness of some areas is affected by outstanding maintenance works. The Registered Manager confirmed that these issues are scheduled to be addressed and that the refurbishment of the first floor bathroom, encasing of the new Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 20 boiler and associated pipework and replacement of the lounge carpet will take place in the very near future. A passenger lift provides access to all floors above ground level, but at the time of the inspection this was awaiting repair. The repair was reported to have been delayed due to the necessity of a new part being made. The Registered Manager and staff spoken with all confirmed that appropriate arrangements had been made with residents to ensure they are able to safely move around the home in the interim period. A general requirement has been made to ensure that all outstanding maintenance works are completed and that the home continues with its plan to redecorate and refurbish in a timely way. Resident accommodation comprises of seven single bedrooms, one of which has en-suite facilities. There are also two double rooms. Those people who share a bedroom have made a positive choice to do so. This is evident in that one room is occupied by a couple and the other by two close friends. The kitchen, reception room and lounge / dining room provide residents with sufficient communal space to meet their needs. The reception room is the designated smoking area for the home. At present, three of the residents smoke. It was confirmed that some staff also use the smoking area and the Registered Manager has been asked to consider this practice. The home was found to be clean, tidy and hygienic at the time of the inspection. The infection control issues raised at the previous inspection have been addressed and as such the laundry room has been totally refurbished and staff now have colour coded protective clothing for use in the kitchen. Whilst on a tour of the home, the Inspector noticed that two bathrooms did not have hand drying facilities. This was raised with the Registered Manager who immediately ordered paper towel dispensers which will be installed on arrival. The Registered manager has also agreed to supply portable alcohol gel to all staff so they can clean their hands between entering different residents’ rooms. As these matters were being addressed prior to the end of the inspection, they have not been made requirements although will be followed up at the next inspection. Cristos DS0000014194.V366622.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): 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated and competent team of staff and are protected by the recruitment procedures. Staff have both the skills and support to enable them to perform their roles effectively. EVIDENCE: At the time of the inspection, the atmosphere was observed to be friendly and relaxed and the positive relationships between staff and residents were obvious. The seven residents spoken with all spoke highly of the staff team and said “they are nice people” and “they are helpful”. The home was staffed by the Registered Manager, Deputy Manager and a Support Worker at the time of the inspection and this was the usual ratio according to the rota. It was expressed by the Registered Manager and staff that there would always be a minimum of two staff on duty during the day and one waking staff member at night. Either the Registered Manager or Deputy Manager is always on call. Discussion with residents, staff and management provided feedback that staffing levels are currently adequate for the needs of Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 22 the residents. The majority of the residents are self-caring and also go out independently. Discussion with the Registered Manager and examination of three staff files identified that staff training is ongoing. There was documentary evidence that new staff members are in the process of completing an induction programme in line with Skills for Care. Staff files also provided evidence of a robust system of recruitment being in place – with all the correct documentation and checks being in situ. Staff confirmed that they have access to a raft of mandatory and specialist training including; fire safety, first aid and safeguarding adults, epilepsy, manual handling, infection control and personal relationships and sexuality. The Registered Manager has a training matrix to ensure that regular refresher training is carried out for all staff. The home has also demonstrated a commitment to National Vocational Training (NVQ) with five staff having completed the NVQ Level 2, one staff member working towards NVQ 3, another NVQ 2 and two new staff waiting to be enrolled. The Registered Manager and staff spoken with confirmed that staff meetings are conducted every two months and that minutes from these meetings are recorded. The Deputy Manager undertakes staff supervision sessions, although the Registered Manager did state that not all staff receive a minimum of six sessions every year. As the Registered Manager is aware of this shortfall, it is not reflected as a requirement of this inspection but will be followed up at the next inspection. Cristos DS0000014194.V366622.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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the home being run by an experienced and dedicated Registered Manager who ensures that the home is run safely and effectively. The home would further benefit from formalising the systems in place to selfaudit and monitor. EVIDENCE: The Registered Manager has a significant number of years experience in owning and managing the home and continues to demonstrate an in depth knowledge of the daily running of a service for older people who have learning disabilities. Conversation with staff and residents provided positive feedback about how the home is managed and the Registered Manager was described as “approachable and supportive” and “she encourages new ideas”. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 24 There are some mechanisms in place for the manager to obtain feedback on the services of the home and whether it is achieving its aims and objectives. These include: feedback questionnaires, residents and staff meetings. Whilst it is evident that the home does make changes and improvements on the basis of stakeholder feedback and self-audit, the home does need to become more robust with how it records and evidences these developments. The Inspector had a lengthy conversation with the Registered Manager about the importance of quality monitoring and in particular, comprehensive completion of the Annual Quality assurance Assessment sent out by the Commission each year. The Registered Manager has agreed to place more focus on this area and to enrol in a training course to further develop her skills. The Registered Manager confirmed that the home continue to undertake various health and safety checks and that a new company has been employed to undertake a full audit of the home in respect of fire safety. It was also confirmed that the local Environmental Health Department had recently visited and that home has successfully completed the Safer Food, Better Business pack. The Inspector did not have cause to question the way health and safety is maintained and therefore records in respect of health and safety were not inspected on this occasion. Cristos DS0000014194.V366622.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 2 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 3 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Cristos DS0000014194.V366622.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 YA19 Regulation 12(1) Requirement The Registered Manager must ensure that each service user has a comprehensive health action plan in place which includes personal guidelines for the administration of homely remedies. The Registered Manager must ensure that an appropriate cupboard is purchased for the safe storage of any controlled medication. The Registered Manager must ensure that the identified maintenance works are completed in a timely way. This relates to the repair of the passenger lift, covering of new pipework and the refurbishment of the first floor bathroom. The Registered Manager must improve its system of monitoring and recording quality audits and in particular ensure that any future Annual Quality Assurance Assessments are comprehensively completed. Timescale for action 01/09/08 2. YA20 13(2) 01/09/08 3. YA26 23(1)(a) 01/08/08 4. YA39 24 01/09/08 Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 27 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. 2. Refer to Standard YA22 YA24 Good Practice Recommendations It is suggested that the home introduce a dedicated book or folder for the recording of any complaints or compliments. It is suggested that the home reconsider the policy to allow staff to smoke in the reception area of the home. Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 28 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 Cristos DS0000014194.V366622.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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