Care Home: Pengarth Road (57)

Similar services:

• Ashlong House
• Norbury Crescent (30)
• Edenvale
• Wadham Avenue
• Chatsworth Care - Dawson House
• Cowden Road, 52 - 54
• Chatsworth Care - Tudor Lodge
• Foxley Lane (121a)

What the care home does well Records seen were well maintained and care plans were up to date. Care plans reflected resident needs and showed how these were to be met. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. The home had access to a mini-bus, which helped with outings and transport in general for the residents. Attention was given to ensuring equipment provided was safely maintained. All bedrooms were used for single occupancy, which afforded the residents privacy. What has improved since the last inspection? The home has a newly registered manager who is well qualified and experienced and staff members interviewed talked positively about the appointment and felt that he is approachable and motivated to provided an effective service for residents. Four out of five requirements and two recommendations made at the previous inspection had been addressed. The level and range of activities for residents has improved and staff members are making good efforts to make these more person individualised for residents. What the care home could do better: The Service User Guide and Statement of Purpose and Contracts need to be updated to ensure full information is available for potential and existing residents and their relatives. Several areas of flooring in the home should be reviewed to consider whether replacement is needed. The furnishings in the sitting room must be replaced and an area of ceiling repaired. The company should review the budget for Maintenance and /repair, to assess whether this is currently adequate for the home. The home still needs to implement service user meetings and an annual survey of the views of service users, their relatives and advocates and involved professionals in commenting on how the home is run, and this information made public. CARE HOME ADULTS 18-65 Pengarth Road (57) 57 Pengarth Road Bexleyheath Kent DA5 1DS Lead Inspector Keith Izzard Unannounced Inspection 6th November 2007 10:00 Pengarth Road (57) DS0000037816.V350885.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 Pengarth Road (57) DS0000037816.V350885.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. Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pengarth Road (57) Address 57 Pengarth Road Bexleyheath Kent DA5 1DS 01622769100 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) pengarth@mcch.org.uk www.mcch.co.uk MCCH Society Ltd Mr Kofi Pepra-Freduah Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 Brief Description of the Service: The home provides a long- term care service for four men with a severe learning disability, who, for the most part, have challenging behaviour and autism. O Briens five accomplishments of community services are used as a set of standards that the home aims to provide for service users. The home provides 24- hour support with waking night staff provision. Daytime opportunities/ are provided both through day centres operated by Bexley Council and within the home. The home receives extensive input from the community learning disability team, around the area of challenging behaviour. Over the past year few months the home has been running at full occupancy of five residents. The home is now jointly managed with another home for two severely learning disabled residents that is very close by. The current fees are £1909.00 per week. Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over a period of 6.5 hours on 06/11/07. Three members of staff and the manager assisted the Inspector. All the residents were seen in the home as all five currently accommodated were at home on the day of inspection. The service was last inspected in February 2006. The inspection included a review of information received about the service, a tour of the premises, inspection of records, talking to and observing residents’ interaction with members of the staff team. Following the inspection contact was made with relatives and other interested parties to get their views of the service. These were all positive including two from visiting professionals. There was a happy and positive atmosphere in the home on the day of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. Overall, the home provides a good service for residents who appear to be happy and content in their home. What the service does well: Records seen were well maintained and care plans were up to date. Care plans reflected resident needs and showed how these were to be met. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. The home had access to a mini-bus, which helped with outings and transport in general for the residents. Attention was given to ensuring equipment provided was safely maintained. All bedrooms were used for single occupancy, which afforded the residents privacy. Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 6 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. Pengarth Road (57) DS0000037816.V350885.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 Pengarth Road (57) DS0000037816.V350885.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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information provided about the home needs to be updated. Residents needs are assessed prior to their admission to the home, or soon after in respect of emergency admissions. Residents are provided with appropriate contracts, however, fees must be clarified and the documents signed by residents or their representative EVIDENCE: Standard 1 In view of the recent appointment of the registered manager and other staff changes it was advised that the Statement of Purpose and Service User Guide required updating. This should include the contact details for CSCI and cover all the areas required within Schedule 1 of the National Minimum Standards for Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 9 Younger Adults. See Requirement 1 Standard 2 Since the previous inspection in November 2006, the home had admitted a new resident. This was an emergency admission and consultation had appropriately taken place with the commission because of the circumstances. By definition it was not possible to for staff of the home to have conducted or received a full assessment of needs prior to the resident’s admission. However, it was noted that both the home and care management staff had provided this information within a reasonable timescale after admission and reviews were quickly organised in order to create a viable care plan for the interim period prior to a permanent long term alternative placement being found. It has been previously noted that the home fully complies with this Standard and in view of the circumstances outlined above this remains the case. Standard 5 The home has not complied with this Standard over several; previous inspections and it was pleasing to note that this had finally been complied with. A well-designed contract has now been provided for each of the long-term residents that had been designed in pictorial form in order to assist those with learning disability and communication difficulties. The contract did not however, include information about the fees being charged, nor were the copies signed by the resident or their representative, this should be rectified as soon as possible. See Recommendation 1 Pengarth Road (57) DS0000037816.V350885.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs and personal goals for each resident were recorded in their personal care plan. Comprehensive plans were developed to manage any potential risks either to residents or staff members. EVIDENCE: Standard 6 Two care files and individual plans were examined in respect of two service users, including the person most recently admitted to the home. Individual plans were comprehensive and involved service users and their representatives, including family or advocates and other professionals involved. These plans are reviewed with outcomes clearly stated and agreed by all participants. Staff members interviewed stated that care plans were reviewed, during both staff and individual supervision meetings. Records seen Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 11 were comprehensive and up to date and showed that residents received annual reviews. Residents’ records included risk assessments. In view of the dependency of the residents in the home they required staff to assist them with all aspects of their lives. Where risks were identified procedures and care plans reflected how these were being managed. Additionally, clinical meetings with CLDT are also taking place when specialist individual support with complex health problems are needed. Standard 7 Interaction between staff and service use, observed by the Inspector, demonstrated choice being encouraged by staff members in relation to activities taking place. The level of disability and communication difficulty of service users is such that staff members find it very difficult to meaningfully engage service users in participating in the running of the home and contribute to policies and procedures. On a daily basis, however, staff members do make attempt to involve service users in simple domestic activities such as putting their laundry away and simple preparation for meals and this was evidenced in the daily diaries, the activities file and within tasks for staff listed in the shift planners. Two staff members interviewed said they endeavoured to involve residents in decision making based on their individual communication and comprehension. This is inevitably restricted by the severe communication difficulties of the residents and depends heavilgy on staff interpretation and historical knowledge of residents likes and dislikes, these are recorded in order to assist any staff that do not know residents well. Staff members were observed communicating with residents and involving them in whatever was going on in a professional and caring manner. Standard 9 Risk assessments are available in all service user’s care files and are readily available for all bank or agency staff who may be less familiar with service user’s needs. Any restrictions placed are few and would be for the safety and welfare of service users, for example not leaving the home unaccompanied. Evidence was available from the service user’s records examined that they are enabled to express choice in what they do and staff record these occasions. Pengarth Road (57) DS0000037816.V350885.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): 11—17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents’ bur further efforts are required in respect of increasing the level of activities provided. Residents’ rights and responsibilities were recognised in their daily lives. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standards 11-14 Evidence was available from the care files of service users that opportunities are being made available for the personal development of residents. Although, Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 13 owing to the level of learning and physical disability and associated communication difficulties none of the service users have been identified as being able to participate in employment or further education via day centres. Staff supported residents to develop daily living skills in line with their individual ability. The Inspector examined a list of activities for service users that is updated weekly and notes are recorded in the daily diary and staff communication book of those activities that are planned for service users. Extensive support is available to the home from Psychiatry, Psychology, Specialist Community Nursing, CLDT, Speech and Language therapy and also from Occupational Therapy, Physiotherapy, Chiropody and Aromatherapy. Much of this input is focussed on responding to challenging behaviour and other complex health needs. Service users are encouraged to participate in household tasks when identified as safe to do so in terms of possible challenging behaviour and in accordance with guidance in their individual risk assessments. None of the service users in the home have been identified as having any specific spiritual needs. The Inspector was pleased to note that a previous recommendation that the level of activities be increased, for example, by developing shopping trips to obtain clothing or other personal items had been taken on board by staff members. Two residents have been encouraged to choose and purchase their own toiletries with staff assistance. Staff members have developed a colour coding system to facilitate another resident being able to choose which CD’s he wants to play. Another resident has overcome his fear of swimming by using special buoyancy aids that have made the sessions fun for him. The Deputy manager is in the process of making a pictorial chart that will help residents understand what activities are available. This is a good initiative. Standard 15 Staff members actively support and encourage family contact; two residents have advocates as well as parental involvement is decreasing. Through the various activities and outings provided residents are provided with some opportunity for meeting with other people, however, staff report that there are no relationships of significance other than family, staff or advocates for any of the residents. It was also reported that there are no issues in respect of expressed sexuality that need to be addressed, as such areas are already known to staff members within the care planning process. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping tips. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise in activities of their own choosing. Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 14 Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food was seen stored in the home. The home has the advantage of the services of a ”Homemaker” who largely attends to the cooking of meals and other domestic areas. The likes dislikes and special requirements of all residents were recorded and staff members well aware of them. Pengarth Road (57) DS0000037816.V350885.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. Staff members worked in conjunction with other external health professionals in order to maintain and improve resident’s health and wellbeing. The administration of medication was well organised. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Care plans seen showed how personal care needs were to be met. It was not possible for all residents to comment on whether this suited them or not. None of the residents in the home were able to give feedback about any aspect of the service, owing to the their individual communication difficulties. Daily records were kept to show the care provided and activities the residents were involved with. All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 16 with the community learning disability team to support staff with meeting residents’ needs. Standard 19 Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example OT’s Physiotherapists, Speech and Language Therapists, Psychiatrist and Dietician. Any nursing care needs would be commissioned via the GP from the local District Nursing service or Community Psychiatric Nurse and currently one community nurse attends one resident because of leg ulcers. All residents require considerable assistance with their personal care needs. On the day of inspection residents appeared adequately and tidily dressed in age appropriate clothing. Personal appearance had been attended to and staff members were observed to be sensitive and respectful to residents. Standard 20 Due to the level of disability, residents are not able to self medicate and would not be able to do so without a high degree of risk. Medication is stored in a locked cupboard in the hallway. Medication is the responsibility of the designated person in charge on all shifts and only permanent staff that have received training are authorised to administer medication. Both MAR sheets for the two residents case tracked were examined and checked against stored medication and found to be accurate. The administration, receipt recording, handling and disposal of medicines met the Standard. The home has a controlled drug for one service year it was noted that this drug was retained with in a separate locked box within the lockable medicine cabinet and that a separate log was retained for the administration of the medication signed by two people and witnessed, as required. Pengarth Road (57) DS0000037816.V350885.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. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service the facility and a book provided in the entrance area for the purpose of encouraging visitors to the home to register any concerns or compliments in writing. One complaint had been made to the provider direct regarding delays to a toilet being repaired. This matter was then addressed appropriately but should be recorded within the complaints log. See Recommendation 2 No complaints about the home had been received the Commission since the last inspection. None of the residents have the ability to raise concerns and observations by the Inspector indicated that they were happy within their home and the service provided for them. Standard 23 Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 18 The home had policies and procedures in relation to adult protection. One adult protection matter had arisen since the previous inspection. This was an allegation that a resident had been slapped by a staff member made by another staff member. The matter was fully investigated under Safeguarding Adult Procedures and the member of staff appropriately suspended whilst this was conducted. The allegation was not substantiated and the staff member was subsequently reinstated. The Inspector was satisfied that correct procedures had been followed including a Regulation 37 significant notification report to CSCI at the time. No other incidents had been reported to CSCI since the previous inspection. The home had copies of the London Borough of Bexley Safeguarding Adults Procedures and a company whistle-blowing policy. Staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. Robust systems were in place to safely manage resident’s personal finances as The Inspector examined the system for dealing with the personal monies of two service users within the home, and found it to be accountable and with a clear audit trail. Additionally, the home is regularly audited via the programme of monthly visits undertaken on Regulation 26 visits by the Responsible Person. Pengarth Road (57) DS0000037816.V350885.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 good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment but more attention is needed to enhance the comfort and homeliness in the communal areas. The home was clean and hygienic throughout. EVIDENCE: Standard 24 A tour of the building was conducted and it was noted that the sitting room area was in need of replacement or refurbishment of comfy chairs and attempts should be made to make this room more homely. An area of wall/ceiling needs repair where plastering has been damaged. In several areas, despite deep cleaning, carpeting has become stained and a review of flooring is recommended to assess whether some should be replaced and Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 20 whether the current budget for repairs and maintenance is sufficient for the home. See Requirement 2 & Recommendation 3 Otherwise the home was maintained to satisfactory standard and no significant health and safety issues were identified. Standard 30 On the day of inspection the home was clean, bright and airy and free from offensive odours throughout. Systems are in place to prevent the spread of infection. Overall, it was noted that the laundry area was satisfactory, although very cramped, with adequate equipment for dealing with soiled articles. Domestic cleaning materials are stored in a locked cupboard and COSH procedures are readily available for staff members performing domestic tasks. Pengarth Road (57) DS0000037816.V350885.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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and cared for by competent and qualified staff members who act as a team to meet their needs. Recruitment procedures were good with all the information required by regulation being included. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff, the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 22 content within their environment and responding positively to any staff interventions, such as assistance with eating or engagement in activities. The home does not currently have the required 50 minimum of care workers trained to NVQ Level 2. The Registered Manager stated that this would be achieved by March 2008 as four care staff members are currently undergoing the training. Standard 34 All of the staff employed had been previously checked in respect of recruitment practice by the inspector in previous inspections, therefore this Standard remains met. Standard 35 Staff members interviewed, presented as clear about their roles and responsibilities and stated that they had received adequate training in accordance with this Standard. Evidence was available from the personal training records examined that a satisfactory level of training had been undertaken and was being planned for the future. Annual updates in fire training and moving and handling had occurred alongside subjects such as person centred care planning and infection control. Pengarth Road (57) DS0000037816.V350885.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. Service users benefit from a well run home. Surveys of residents’ relatives and professionals views on the running of the home must be conducted and made publicly available. The health and welfare of service users are promoted and protected EVIDENCE: Standard 37 At the previous inspection a requirement was made that a Registered Manager must be appointed this had been an outstanding requirement for some time Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 24 and the Inspector was pleased that this had now been complied with. The newly appointed Registered Manager has considerable experience and the necessary qualities and skills to provide a good quality service. Staff members interviewed stated that the acting manager is approachable and supportive and would not hesitate to discuss any concerns with him about the home or the welfare of service. Communication within the home was of a good standard with team meetings held regularly. The manager has undertaken training in order to update his own skills and knowledge and is currently undertaking the Registered Manager Award and hoping to complete this early in 2008 and the nationally recognised ”Tizzard” training at Canterbury University.. Standard 39 The home has partially implemented a quality review system in place to record the views of residents, relatives, advocates and visiting, or involved professionals. However, this has still not been fully implemented and must be as soon as possible, the results published and generally made available, including CSCI. See Partially Restated Requirement 3 The home receives regular monthly visits under Regulation 26 and produces reports as required and submits these to the CSCI. Two questionnaires returned by visiting professionals and one by the parent of a resident were broadly complimentary about the service provided by the home. Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. COSHH procedures were in place and hazardous items locked away. A number of areas were picked at random and checked against the pre inspection questionnaire (AQAA), in respect of routine health and safety checks such as fire drills and other areas requiring maintenance checks. Fire drills had been held regularly within quarterly periods at different times of the day and had included night -time care staff and a record of weekly testing of call points was also maintained. Pengarth Road (57) DS0000037816.V350885.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 2 2 3 3 X 4 X 5 2 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 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 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 26 Yes 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 YA1 Regulation Requirement Timescale for action 01/03/08 2. YA24 3. YA39 4&5 The Registered Person must &Schedule unsure that Statement of 1 Purpose and Service user Guide are updated to include all the information required in Schedule 1. 16 & 23 The Registered Person must 01/03/08 ensure that suitable comfortable easy chairs are provided in the sitting area. The damage to wall/ceiling repaired. 24 The Registered Person must 01/03/08 ensure a system is fully in place to review and improve the quality of care provided in the home. Outcomes on the quality assurance reviews must be made available to residents, relatives the Commission and others. Partially Restated Requirement: previous timescales of 1/11/05 and 01/04/06 & 01/01/07not met. Pengarth Road (57) DS0000037816.V350885.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. 3 Refer to Standard YA5 YA22 YA24 Good Practice Recommendations Contracts for residents should include information about the fees being charged, and copies signed by the resident or their representative, It is recommended that all complaints be logged including any made to the head office of the company direct. Carpeting in several areas has become stained and a review of flooring is recommended to assess whether some should be replaced and also whether the current budget for repairs and maintenance is sufficient for the home. Pengarth Road (57) DS0000037816.V350885.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Pengarth Road (57) DS0000037816.V350885.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!