Care Home: Trent House

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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 activitiesThe home is an attractive and spacious property with a location that facilitates independence. The residents have been fully involved in the decoration and furnishing of the home. Each resident has their own key to their bedroom. What has improved since the last inspection? The standard of documentation and recording has improved, particularly in relation to recruitment and key policies and procedures which enables the home to evidence the steps they take to protect residents. The organisation has developed its systems for monitoring quality assurance and as such is proactive in identifying and implementing its own improvements. What the care home could do better: Approaches to care need to be more person led, with a particular emphasis on health action planning and the setting of meaningful goals. Shortfalls in the number of staff achieving National Vocational Qualifications (NVQ) in Care need to be addressed. The feedback received from stakeholders must be collated and published to demonstrate how the service responds to the views of interested parties in respect of shaping the future of the service. CARE HOME ADULTS 18-65 Trent House Balcombe Road Horley Surrey RH6 9SW Lead Inspector Lucy Green Unannounced Inspection 13th February 2008 11:00 Trent House DS0000014804.V358102.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 Trent House DS0000014804.V358102.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. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trent House Address Balcombe Road Horley Surrey RH6 9SW 01293 785938 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) Ashcroft Care Services Ltd Sharon Ann Davies Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That no more then 6 male and/or female service users in the category of learning disability be accommodated. 10th October 2006 Date of last inspection Brief Description of the Service: Trent House is registered to provide personal care for up to six people with learning disabilities. The home specialises in providing support for people who may present behaviours that challenge the service. The home is situated in Horley, West Sussex with transport links to the nearby main town of Crawley. Resident accommodation is provided in two buildings; the main house and a separate unit that provides semi-independent living for two people. The main house provides four single bedrooms, a large lounge, dining room, kitchen and two bathrooms. The other unit is split into a flat with bedroom, kitchen and bathroom facilities and a bed-sit that provides a bedroom and washing facilities. The person living in the bed-sit accesses the kitchen and lounge facilities in the main house. Both units enjoy access to the rural grounds with a large garden, ample parking and an outside swimming pool. More detailed information about the services provided at Trent House, including the range of fees can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available on request from the home. Trent House DS0000014804.V358102.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 Trent House 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 three and a half hours on Wednesday 13 February 2008 between the hours of 11am and 2:30pm. The site visit included a partial tour of the premises and an examination of some medication, care and staffing records. The Inspector observed the interaction between staff and residents as they planned activities and prepared the lunchtime meal. Throughout the inspection process, the Inspector met with the four people living in the main house. The two people accommodated in the semiindependent living unit were out for the duration of the visit and therefore it was not possible to meet them. The Inspector spoke individually with the Registered Manager and interviewed two staff members 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. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 6 The home is an attractive and spacious property with a location that facilitates independence. The residents have been fully involved in the decoration and furnishing of the home. Each resident has their own key to their bedroom. 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. Trent House DS0000014804.V358102.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 Trent House DS0000014804.V358102.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): 2&3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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. Compatibility of new and existing residents will be assured providing the Registered Manager is integral at the assessment stage. EVIDENCE: There have been two admissions to Trent House since the last inspection in October 2006 and the assessment information for these two people was viewed. This provided evidence that a thorough assessment process had been undertaken prior to both of these people coming to live at the home. 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. The Registered Manager confirmed that detailed transition plans had been put in place for both people that included the opportunity for overnight stays. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 9 It was identified that whilst the Registered Manager had been involved at the transition stage for both of the individuals admitted since the last inspection, the actual initial assessment had been completed by the Clinical Team at Ashcroft Services. Pre-admission assessments are also held centrally, although, much of the information is transferred by the Clinical Manager by way of developed guidelines and risk assessments. The Inspector stressed to the Registered Manager that it was vital she play a key role in assessment process in order to ensure compatibility with existing residents. Similarly, all assessment information should be stored in the home for reference as appropriate. Through discussion with the Registered Manager, staff and a review of care plans it was evident that there is currently discussion about one resident being supported to explore new placements. This individual chooses not to integrate with the other people that live at Trent House and there have been some instances where the ability to meet the needs of everyone accommodated at Trent House has been difficult. Consequently, the incompatibility issues generated some incidents within the service. Whilst, the home has demonstrated that it is currently able to control the impact that this has on the people living at the home, it is recognised that this is only possible in the short term and as such it is expected that a permanent solution is secured in the near future. Trent House DS0000014804.V358102.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 in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans include detailed information and guidelines to support individuals, but outcomes would be further improved if they were more strategically used to formulate life goals and develop skills. Residents benefit from support that they are consulted about and 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 two residents, which included a partial examination of their care plans, activity schedules and a discussion with the Registered Manager. The Inspector was able to meet with one of these residents during the course of the inspection. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 11 The Registered Manager confirmed that the content and layout of care plans was in the process of being changed and that staff were in the process of attending training in person centred planning. The information currently in place for residents provides detailed support guidelines about daily care needs, including a range of risk assessments and behavioural support needs. This approach to care planning however, does not demonstrate how the home supports residents to strategically formulate life goals and develop their independence. The home has begun to develop and explore more person centred approaches to care planning, but more work in this area is needed. The Registered Manager demonstrated a knowledge and understanding of what was necessary to move these care plans forward. As this piece of work has been identified by the home as going to take time to complete in a meaningful; way, a timescale of six months has been attached to the requirement. It is expected that this piece of work is completed in a timely way and evidence of this should be included in the home’s next Annual Quality Assurance Assessment. A full care review is held at least once every six months, with interim monthly reports completed by the key worker. Minutes from these meetings were viewed and found to be detailed and focused and adopt a multi-disciplinary approach. Trent House DS0000014804.V358102.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, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are appropriately supported to lead independent lives and to develop their educational, vocational and social skills. 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, educational and vocational activities that are meaningful to them. When the Inspector arrived at Trent House, all of the residents were out. Two residents had gone swimming and later returned, one of which then went out again to visit the chiropodist and then to walk her dog and the other went to undertake a voluntary job in the afternoon. A third resident went out for a walk with a staff member and another was in the community shopping. One Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 13 resident visited the doctor and then returned home for an in-house music session. The final resident, was out for the duration of the inspection visiting family independently. It was highly evident throughout the inspection, that residents lead busy and fulfilling lives, with lots of opportunities to go out. One resident told the Inspector “I like it here and I wouldn’t want to be anywhere else”. The resident went on to tell the Inspector all the things they like to do including; cooking, swimming, youth clubs and shopping. Another resident told the Inspector they were going shopping, bowling and out for lunch which they were clearly excited about. Where possible, the home has arranged for residents to develop their vocational experience and for one resident this means undertaking voluntary work on behalf of the local council. Ashcroft Care Services as an organisation also offers some paid work for residents and as such one resident from Trent House told the Inspector that they undertake a post run for the local homes three days each week. In order to develop excellent outcomes in this area, the Registered Manager is aware that the home needs to demonstrate how the activities and goal planning are linked to person centred plans of care which support individuals to achieve live goals and maximum independence. The home has a positive approach to enabling residents to maintain contact and relationships with families and friends. There was evidence in the care plans that the home supports residents to meet with and receive visits from their relatives and friends. The Registered Manager and two staff spoken with understand the importance of good relationships with other stakeholders. One resident told the Inspector that they were in a relationship with someone outside the home and explained how the home had supported them to go out for dinner for Valentines Day. Resident reviews include the opportunity for residents’ relatives/representatives to attend if the resident wishes. Meals at Trent House are prepared according to a menu that is drawn up by residents on a weekly basis. Discussion with two residents evidenced that they are fully consulted in the planning and preparation of meals and stated that the menus on display reflect their choices. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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 is evident that appropriate referrals are made to external professionals, including GP’s, psychiatrists and dieticians as necessary. There is evidence in respect of the two people whose care was tracked, that they are regularly weighed and records maintained. Personal care was observed being provided in a sensitive and respectful way. The home has not currently introduced health action plans in line with Valuing People. Whilst care plans provide detailed information about health care support, it is required that these action plans are introduced. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 15 Medication systems were assessed by way of a review of records, storage and discussion with the Registered Manager. The medication policy was not inspected on this occasion. Both the administration, recording and storage of medication are satisfactory and detailed guidelines are in place regarding the use of ‘prn’ medication. Care plans contained evidence that medication is reviewed at least on annual basis. The Registered Manager reported that staff undertake medication training with the supplying pharmacy and confirmed that no staff handle medication until they have successfully completed this training. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and visitors to the home benefit from and are protected by, the open culture at Trent House. EVIDENCE: The home has a complaints procedure in place, which is accessible to both residents and visitors. A complaints book is in place, which evidences that even minor complaints are dealt with appropriately. The Commission has not received any complaints about the services at Trent House in the last twelve months. 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, both informally every day and formally through monthly meetings with their key worker. 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 systems for supporting residents’ with their finances which include monies being checked and signed for. The Registered Manager and two staff spoken with demonstrated that they were aware of their responsibilities in respect of protecting vulnerable adults and had completed relevant training. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 17 In line with a requirement from the last inspection, the home has reviewed and developed its policies and procedures in respect of safeguarding adults and whistle-blowing. The home does not however currently have a copy of the updated local multi-agency policies and procedures for the safeguarding of vulnerable adults and a copy of this document must be obtained. Trent House DS0000014804.V358102.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 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Clients benefit from a homely, safe and comfortable environment that meets their needs. EVIDENCE: The home is situated in Horley, West Sussex with transport links to the nearby main town of Crawley. Resident accommodation is provided in two buildings; the main house and a separate unit that provides semi-independent living for two people. The main house provides four single bedrooms, a large lounge, dining room, kitchen and two bathrooms. The other unit is split into a flat with bedroom, kitchen and bathroom facilities and a bed-sit that provides a bedroom and washing facilities. The person living in the bed-sit accesses the kitchen and lounge facilities in the main house. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 19 Both units enjoy access to the rural grounds with a large garden, ample parking and an outside swimming pool. The Inspector undertook a partial tour of Trent House and the four residents living in the main house showed the Inspector their bedrooms which were found to be personalised and well furnished. The four residents spoken with confirmed that they had been involved in choosing the decoration and furnishing of their rooms. It was not possible to view the bed-sit and flat accommodation as the residents living in these areas were out for the duration of the inspection. Residents hold keys to their rooms and staff respect their private space, the Inspector had no reason to have concern about the way these two people are accommodated. All parts of the home visited were tidy, clean and hygienic. The only issue raised with the Registered Manager was that one resident was noticed to prop open their bedroom door to allow their dog to move freely around the home. It was suggested that the Registered Manager should liaise with the fire brigade and look a fitting an approved hold open safety device if this is an ongoing practice. Trent House DS0000014804.V358102.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, 33, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a dedicated and competent team of staff and are protected by the robust recruitment procedures in place. 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 Registered Manager confirmed that typical minimum staffing levels provide two staff on duty between 7am and 9am, five staff working between 9am and 4pm and four staff between 4pm and 9pm. At night the home is staffed by one waking and one sleep-in support worker. It was stated that staffing levels are provided flexibly to meet the needs and activity plans of the residents, but that the home would never be staffed with less than three care staff. The rotas viewed reflected these figures as accurate and all parties spoken with believe that current staffing levels are sufficient. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 21 Discussion with two staff and examination of three staff files identified that training is ongoing. There is documentary evidence that new staff members complete an induction programme in line with Skills for Care. Staff files also provide evidence of a robust system of recruitment being in place – with all the correct documentation and checks being in situ. Staff have access to a raft of mandatory and specialist training including; fire safety, first aid, manual handling, adult protection, epilepsy and behavioural support. The staff who met with the Inspector demonstrated a good understanding of the needs of the people they support and confirmed that they felt competent to carry out their roles effectively. Two of the residents who spoke individually with the Inspector confirmed that staff were good at their jobs. One resident commented “I get on well with the staff” and another said “staff are good”. The Registered Manager confirmed in the annual Quality assurance assessment that 32 of the staff team hold National Vocational Qualifications (NVQ) to at least level two. Whilst this figure does not currently meet workforce targets, the home has a system in place to improve this percentage and has demonstrated a commitment to fulfilling this and therefore this is not reflected as a requirement of this inspection. The Inspector saw evidence of regular staff meetings being conducted with minutes recorded. There is a supervision system in place that provides staff with formal 1-1 sessions every month. Trent House DS0000014804.V358102.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 in this area. We have made this judgement using a range of 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. The organisation has systems in place to self-audit and monitor, although would benefit from providing Managers with more supernumerary time to complete their roles. EVIDENCE: Since the last inspection, the Manager has been successfully registered. It is pleasing to report that all feedback received from staff and residents was positive about the current management arrangements of the home. The Manager was described by staff as “supportive and approachable” and was staff member told the Inspector “the management support is brilliant”. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 23 Discussion with the Registered Manager identified that she is currently only allocated one administration day each week. The Registered Manager stated that it is difficult to complete all the required tasks in this time frame and that she has raised this with her Area Manager. The Inspector agrees that whilst the home is being managed effectively, the Registered Manager is required to work additional hours to manage her workload and therefore the home would benefit from an increase to her supernumerary hours. The home has a system of quality monitoring in place with the a representative from the organisation conducting regular visits in accordance with Regulation 26. There was no Regulation 26 report for December 2007, as the individual who undertakes this role is currently on long term leave. It is expected that this function will re-commence this month. There was evidence that annual satisfaction surveys are sent out to stakeholders, although at the current time the results of these have not been formally collated and published. Monthly residents meetings are held and documented. The Annual Quality Assurance Assessment provides evidence that the home has various systems in place to ensure the Health and Safety of the home are maintained. 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. Trent House DS0000014804.V358102.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 X 2 3 3 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 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 3 X X 3 X Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(1) & (2) & 13(4) Requirement The Registered Person must ensure that care plans are developed in consultation with service users in a person centred way. These plans must be in a format that are accessible to service users and staff. The Registered person must ensure that each service user has a comprehensive health action plan in place. The Registered person must obtain a copy of the local multi agency policies and procedures for safeguarding vulnerable adults. Timescale for action 01/07/08 2 YA19 12(1) 01/04/08 3 YA23 13(6) 01/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA3 Good Practice Recommendations Copies of assessment information should be available in the home. The Registered person should be fully involved in the DS0000014804.V358102.R01.S.doc Version 5.2 Page 26 Trent House 3 YA37 assessment of all new service users to ensure they are compatible with the people already living in the home. The Registered Manager should be given additional management time to fulfil her role. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South East The Oast Hermitage Court Hermitage Lane Maidstone Kent 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. Trent House DS0000014804.V358102.R01.S.doc Version 5.2 Page 28 - 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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