Care Home: The Goodwins

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What the care home does well Residents receive good social and healthcare support. Relevant equipment and adaptations are provided for their benefit. The premises are suitable for use by people with learning and some physical disabilities. All residents have lived at the premises for many years and members of staff are aware of how to address their changing needs. Members of staff undertake a variety of training including NVCI (non violent crisis intervention) provided by the company that covers mandatory training and encouragement to obtain NVQ qualifications. This helps staff understand resident`s needs and contributes to keeping them safe and comfortable. The manager and staff recognise the homes strengths and weaknesses and are preparing a plan of action to maintain the strengths and improve on weaker areas. The range of activities for residents has been improved over the past six months and further reflection on the need to develop initiatives is continuing. The difficulties in keeping residents in touch with relatives are recognised and actions are taken to address this. Residents and staff have their meals together and there is emphasis on providing good meals. What has improved since the last inspection? A new cleaning rota is being maintained. Some bedrooms have been refurbished so that people living at the home can enjoy their private space. Some work has commenced on improving care plans even though the company has not yet provided a format best suited to the needs of residents. The manager is progressing some developments, for example, additional access by residents to activities, identification of premises improvement accompanied by a maintenance schedule and review/updating of some aspects of service levels to improve resident`s safety. What the care home could do better: Whilst no new admissions have taken place for many years, the updating of written pre-admission information will be an asset for prospective residents and their advocates. The manager and support workers are aware of the limitations of the current care plan system and daily recording procedure and complete them as required, a revised format would help to enable the needs of residents/goals of care/reviews of care to be more accurately recorded. The Commission understands that a working group is looking at the need for a revised procedure. The premises, whilst safe and comfortable for vulnerable people, should be refurbished in line with the maintenance plan drawn up by the manager. The manager should continue the review and updating of procedures surrounding protection of vulnerable people and introduce the improvements into mandatory training. The revised complaint`s procedure should also be more prominently displayed. In the 2008/`09 AQAA (annual quality assurance assessment), the manager intends to refer to the developments outlined above and all relevant aspects of client support that are under review. CARE HOME ADULTS 18-65 The Goodwins 3 St Richards Road Deal Kent CT14 9JR Lead Inspector Eamonn Kelly Unannounced Inspection 14th May 2008 10:30 The Goodwins DS0000065342.V363465.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 The Goodwins DS0000065342.V363465.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. The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Goodwins Address 3 St Richards Road Deal Kent CT14 9JR 01304 389149 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager Type of registration No. of places registered (if applicable) CareTech Community Services Ltd Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2007 Brief Description of the Service: The service, owned and operated by Care Tech Community Services Ltd., provides support for up to eight people with learning disabilities. These premises are located on the outskirts of the coastal town of Deal close to bus and train services and other community services. Residents have single rooms and the premises have good communal facilities including garden and car parking. Weekly fees range from £1,250 to £2,400. Residents are additionally charged for other items such as hairdressing, chiropody, personal spending, cost of entry to some external amenities, cost of holidays and some transport costs. The Goodwins DS0000065342.V363465.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 that people who use the service experience good quality outcomes. The inspection took place on 14th May 2008 (between 10.30 am and 4.45pm). The methodology used to produce the report included reference to the AQAA (annual quality assurance assessment) submitted by the service, interviews with six members of staff, meetings with or observation of eight residents, review of the premises and checks of records used in the care and support of residents. Outcomes from the previous inspection report were checked. Checks were also made of information known to the Commission about the service. In keeping with the Commission’s policy of looking closely at specific regulations and standards from time to time, some emphasis was placed on this occasion on how well the home meets Standards 23 and 34 (protection and recruitment). The previous report contained one requirements relating to accessibility by staff and visitors to a complaints procedure. The requirement has been addressed. This report contains no requirements. A note is included below about the need for the manager to further develop staff training in the area of protection of vulnerable adults and to update the current policy and procedures. What the service does well: What has improved since the last inspection? The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 6 A new cleaning rota is being maintained. Some bedrooms have been refurbished so that people living at the home can enjoy their private space. Some work has commenced on improving care plans even though the company has not yet provided a format best suited to the needs of residents. The manager is progressing some developments, for example, additional access by residents to activities, identification of premises improvement accompanied by a maintenance schedule and review/updating of some aspects of service levels to improve resident’s safety. 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. The Goodwins DS0000065342.V363465.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 The Goodwins DS0000065342.V363465.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. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Prospective residents have the benefit of having their individual aspirations and needs assessed before they enter residential care to help ensure that they will receive the support they need. EVIDENCE: No new residents have been admitted in the last 7 years. The manager has a range of written pre-admission information about the premises and services provided. This is available to prospective residents and their advocates. The manager is updating these documents so that they accurately describe the services and facilities of the home in the event of any future planned admissions. Information for prospective residents and their advocates is also available from the company’s website. The manager is aware of the company’s policy and procedures for assessing prospective residents and using information at that stage to start an individual care plan. New personal contracts were provided to residents over the past 18 months. These contain good information about the rights and responsibilities of both parties. The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 9 During this inspection, profiles of each resident were discussed in depth with members of staff on duty. All have a good understanding of the disabilities of residents and of the support in place to address these needs. Elsewhere in this report, there is evidence of staff having a good knowledge of resident’s support needs and the individual aspirations of residents being addressed. The Goodwins DS0000065342.V363465.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 good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents have the advantage of being encouraged to make decisions and to express themselves as part of developing their confidence and quality of life. EVIDENCE: Each resident has a plan of care as a component of his/her personal file. The previous inspection report drew attention to the need for a better care plan recording system to be adopted. The organisation has made no further progress on this issue although members of staff are aware of the limitations of the current method. The manager says that consideration is being given by a company working party to improve care plan records. A problem is that the current format is used throughout the company and individual managers cannot alter these to suit individual homes. The current care plan record does not identify all aspects of residents support needs, how these should be addressed and the outcomes of reviews. Additionally, members of staff say that the daily service record completed at the end of each shift is The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 11 cumbersome. In the examples seen, there is, for example, insufficient space to describe events relating to how residents fared during the staff shift in question. In the previous inspection report, attention was drawn to the shortfalls in care plans regarding identification of resident’s aspirations. These deficiencies remain. Nevertheless, in separate meetings with six members of staff there is evidence that resident’s complex support needs are known to staff and these needs are addressed and reviewed. There is some evidence that care managers review resident’s needs at intervals they feel is appropriate. Agency support workers met during the inspection have a fairly longstanding association with the home and they too have a good knowledge of resident’s needs and how these must be addressed. All members of staff met on this occasion have attended NVCI (non violent crisis intervention) training and annual updates. As part of individual resident profiles discussed, there is evidence that members of staff are experienced in working with residents and using this training for the benefit of residents. Reference to such events is included in daily service records but, as referred to above, members of staff regard these as generally unhelpful recording devices. Decisions made on behalf of the people living in the home are well documented. Care plans contain suitable risk assessments the purpose of which is to encourage people living at the home to undertake activities with recognised degrees of risk. Limitations are only made in the person’s best interest and these instances are recorded. Members of staff demonstrated in several cases how they are able to recognise non-verbal cues from residents and respond to their needs. The Goodwins DS0000065342.V363465.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, 12, 13, 14, 15, 16, 17. People who use the service experience Excellent quality outcomes. This judgment was made using a range of evidence including a visit to the service. Routines and activities developed with each resident give them opportunities to exercise preferences on a day-to-day basis. They are helped to take part in activities they enjoy and to be a part of community life. EVIDENCE: Residents are assisted by staff to have suitable activities. As part of this initiative, the services of a specialist agency are used on the premises twice a week to help residents with meaningful activities. One such activity is participation in a sound, vision and relaxation studio. This facility includes a number of tactile interactive objects that can also be used by residents with staff assistance outside the agency sessions. The layout of the premises contributes to resident’s comfort with its conservatory, lounge areas, garden, area that can be cordoned off as a sound/vision studio, dining room and space for in-door activities. People at the The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 13 home used the conservatory and the garden during this inspection visit. The previous report referred to some lack of activities for residents. The manager has increased these over the last six months particularly those available inhouse. Resident’s bedrooms are equipped with audio/visual equipment where this is of benefit to individual residents. The manager described in the annual quality assurance assessment his plans to improve the scope of activities and involvement in decision-making of people living in the home. In the 2008/’09 AQAA, it is his intention to outline further developments in this area of resident support. The weekly activity planner outlines the types of activities arranged for each resident based on his/her aptitudes and capabilities. Because of the very high support needs of residents and to meet changing aspirations, the range of activities varies and changes frequently. Where possible residents are assisted to attend courses at the local college and one is currently attending a cooking course. People at the home are encouraged to maintain contact with relatives. This is described in individual care plans. During profiles discussed with members of staff on duty, it emerged that contact with relatives is often variable and staff make good efforts to take residents to their family homes in other local authority areas as part of plans to maintain contact with families. A mini-bus is available for shopping and other outings involving residents. There are sufficient numbers of staff available as drivers and the evidence is that many outings are arranged. This advantage and others contribute towards helping residents maintain links with the local community. Residents can generally choose when to get up and go to bed, whether to go out or stay in; the home’s daily routines are organised around this concept. There are some more fixed arrangements, for example, attendance on three days a week at a local day centre by some residents. Considerable time was spent during the inspection visit with residents and staff at lunch. The methods used by the chef to vary meals and assess resident’s enjoyment of these are in accordance with the detailed policy of the company. Staff and residents have their meals together. There is a clear record maintained of meals provided and the “food enjoyment/consumption chart” devised within the home, maintained by the chef and reviewed by the manager and staff is an active indicator of the importance allocated to the need for good meals. The Goodwins DS0000065342.V363465.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. This judgment was made using a range of evidence including a visit to the service. Residents receive good physical, emotional and personal support. They are protected by good procedures for administering medication. EVIDENCE: Members of staff support residents in line with details contained in their care plans and their knowledge of resident’s disabilities and associated needs. The home has a key worker system and induction of new staff includes gaining knowledge of how to deal with personal care issues. On the day of the inspection visit there was an acknowledged imbalance in the numbers of female staff on the two shifts but the manager made operational arrangements to deal with this imbalance. There is a clear policy on how personal care is provided by male and female staff. People’s health care needs are assessed and information is updated as necessary in individual care plan files. The company has produced a health action plan for the recording of health care issues and this is being introduced into day-to-day procedures. Resident’s personal files show that residents have access to health care specialists including psychiatric services as required. The The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 15 manager is addressing the need to ensure that all residents have good access to dental services. A chiropodist attended several residents during the inspection visit. On this occasion also, staff took a resident to hospital and, later in the day, it was found that early identification of the problem by staff and early access to medical care had a significant benefit for the resident. A member of staff, at the same time, took another resident to a GP surgery for routine medical intervention. Considerable emphasis is placed by staff on identifying where residents may have pain and in responding to the indicators. Several examples highlighted staff expertise in this area of practice. Medicines are stored in a locked cabinet in secure circumstances. Examples of MAR (medicine administration record) sheets checked suggested the correct procedures are followed for administration and recording. Each MAR sheet contains an up-to-date photograph of the resident and the manager has prepared an accompanying record of the effects of each medicine on individuals. In the examples seen, he alters these records when medications change so the information available to staff is always up-to-date. The company requires all staff involved with administration of medicines to receive mandatory training. The Goodwins DS0000065342.V363465.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. This judgment was made using a range of evidence including a visit to the service. Residents are protected from abuse and are able to make their views and feelings known to members of staff. EVIDENCE: The 2006/’07 AQAA stated that “the company has a thorough complaints policy and complaints are followed through within the set time scale”. Over the past year the service has not responded properly and in a timely fashion where instances involving potential danger to residents occurred. These involved, for example, long delays in repairing a broken down washing machine during winter, delays in addressing significant dampness in the premises, and incidents between staff and residents. The Commission was alerted to these issues by whistleblowers and took appropriate action at the time to encourage the service to review its policies and update methods for safeguarding residents. On this occasion, individual meetings with six members of staff indicated that they would ask the manager to intervene or alert the Commission or other organisation if they felt there were shortfalls in standards of care for individual residents. Support workers said that, over the past year, they have become more confident that the local service now responds more appropriately but some said that the company might still be slow in taking action because of staffing, financial or other considerations. The manager says he is aware of staff views in this regard and welcomes their commitment to good quality care for residents. The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 17 As a result of reflection on how procedures were not effectively followed in the past, the manager is developing training in the area of protection of vulnerable people. This includes the provision of better information at induction stage and, as part of the mandatory training programme for all staff, making them aware of current local authority procedures for safeguarding Adults. The manager is preparing an updated Safeguarding Adult’s policy and complaint’s procedure. He intends to outline these developments in the 2008/’09 AQAA. Examples of the issues he intends to include in the new policy are details of other organisations like the police and local authority that play a part in safeguarding procedures, the process in place in the local council for safeguarding referrals and the local point of contact, advice to staff on how to learn from safeguarding incidents and how such incidents feed into policy and practice in the wider organisation. The Goodwins DS0000065342.V363465.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, 28, 30. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents have the benefit of living in premises that are suitable for the types of support they need. EVIDENCE: In the 2007/’08 AQAA, the manager provided an outline of the state of the premises and improvements necessary. The observations were made when the manager had just taken on the job and, in the meantime, he has achieved progress in some areas. He is aware that the declarations to be made in the pending 2008/’09 AQAA will require determination in carrying them through due in part to the slowness of the company’s maintenance department in responding to requests for refurbishment and maintenance. Members of staff reported they felt that the owning company has expanded too rapidly which has meant delays in meeting refurbishment targets. The layout of the premises contributes to resident’s comfort with its conservatory, lounge areas, garden, area that can be cordoned off as a The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 19 sound/vision studio, dining room and space for in-door activities. There are good car parking facilities including space for the home’s mini-bus. The premises are broadly suitable for the accommodation and support of residents. Each resident has his/her own bedroom and there is good communal space and amenities. Bedrooms reflect the personalities of their occupants and some have special adaptations. Some communal areas require repainting, carpets need to be replaced, the kitchen needs complete overhaul, the ceiling of the dining room needs repair. The manager has produced a maintenance audit to identify areas in need of attention and he has received an indication from the company about when the required refurbishment will take place. Nevertheless, residents live in a safe and comfortable environment. The computer facilities available to the manager and staff are not up-to-date and, for example, problems are encountered with having to send items for typing to another office. A tour of the premises indicated that the home is kept clean and free from odours and members of staff are confident that the revised cleaning rota is proving effective. The Goodwins DS0000065342.V363465.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. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents are in the care of members of staff that are well supported by the company. The use of appropriate recruitment, selection and training procedures contributes to the safety, comfort and protection of residents. EVIDENCE: Meetings with six members of staff indicated that they have received the levels of training considered mandatory by the company. Some said they have received support in achieving an NVQ qualification and some said that, whilst this support is available, they are not taking up the opportunity. Most support workers either have achieved an NVQ award or are discussing a start date with the manager. Those met have undertaken training arranged by the company or provided directly by its training department in moving and handling and updates, medication, infection control, non-violent crisis intervention, first aid and food hygiene. An up-to-date training matrix evidenced the good level of training provided to staff. They said they are encouraged to request places from training programmes publicised and to discuss those they need or are otherwise interested in informally or during formal 1:1 meetings with the The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 21 manager. Support workers undertake a six-month Learning Disability Award Framework (LDAF) induction and foundation training programme. The Commission’s provider relationship managers have accepted the company’s system for carrying out recruitment through its HR department and maintaining centralised records and personnel files. The manager described how individual managers are involved in recruiting and managing staff in cooperation with HR staff. A list of staff kept by the manager that indicates a CRB and POVA check has been carried out for all staff at the home. The numbers of staff on duty on the day of the inspection visit further evidenced by the staff rota supports the manager’s view that he is able to have sufficient staff on duty to support the needs of residents. Apart from the manager, there was a senior support worker and four support workers on duty (both morning and afternoon). In addition a chef was present. On Mondays, Tuesdays and Thursdays and additional support worker is on duty to help with attendance of residents at a day centre. The manager employs agency workers that have a long-standing association with the home and, as evidenced by meeting some agency staff, have a good knowledge of resident’s support needs. Three support workers (two awake and one asleep) are on duty at night. The Goodwins DS0000065342.V363465.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, 39, 42. People who use the service experience good quality outcomes. This judgment was made using a range of evidence including a visit to the service. Residents live in an environment that is well managed. They are benefiting from improvements in the way the business is conducted. The management and administration of the home is based on openness and respect and has effective quality assurance systems. EVIDENCE: The manager conducts the home in the interests of residents supported by the organisation’s strategic, financial and operational systems. For example, he says he is confident that the budget for staffing hours is sufficient for meeting the needs of residents. The manager has a clear understanding of the key principles and focus of the service. The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 23 There is also a focus on person centred thinking with residents shaping service delivery. There is a strong ethos of being open and transparent in all areas of running of the home. This is evidenced in the way the manager is updating procedures for maintaining the safety of residents and increasing staff awareness in this area of service as referred to earlier in this report. The manager intends to describe in the 2008/’09 AQAA (annual quality assurance assessment) the extent of improvements now in place and planned. This document lets the commission know about changes providers have made and where they still need to make improvements. The manager showed how this is being completed and, for example, how he will be able to make a declaration that all necessary safety checks and associated certificates are in place. The service has good policies and procedures that the manager reviews and updates in line with current thinking and practice. He ensures that all members of staff follow the policies and procedures of the home. The home has a clear health and safety policy. The manager is confident that all members of staff are aware of the policy and are trained to put theory into practice. He says that regular random checks take place to ensure they are working to it. Safeguarding is given high priority and the home provides a range of policies and guidance to underpin good practice. This is an area of practice that is currently subject to thorough review and updating by the manager following some slowness during 2007 by the company to address issues brought to its attention. The manager will submit an application within the coming weeks to be registered with the Commission and is close to completing the Registered Manager’s Award. Quality assurance and monitoring procedures are in place for efficient running of the home and deliver effective outcomes for the people who use the service. The company introduced a quality assurance department in 2007 that, according to the description given by the manager, is developing a range of quality assurance procedures. Recent examples of Regulation 26 reports following visits by a representative of the company indicate that emphasis is placed on recognising improvements necessary for the continuing good support of residents. The Goodwins DS0000065342.V363465.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 x 28 2 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 2 3 x 3 x LIFESTYLES Standard No Score 11 4 12 3 13 3 14 4 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 The Goodwins DS0000065342.V363465.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Goodwins DS0000065342.V363465.R01.S.doc Version 5.2 Page 26 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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