Inspection on 07/08/08 for Mariners Folly

This is the latest available inspection report for this service, carried out on 7th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mariners Folly 29/12/06

Mariners Folly 15/06/06

Mariners Folly 25/10/05

Mariners Folly 18/05/05

Mariners Folly 12/10/04

Mariners Folly 14/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Mariners Folly 194 Parrock Street Gravesend Kent DA12 1EW Lead Inspector Robert Pettiford Unannounced Inspection 7th August 2008 09:00 Mariners Folly DS0000050495.V365444.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 Mariners Folly DS0000050495.V365444.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. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mariners Folly Address 194 Parrock Street Gravesend Kent DA12 1EW 01474 361935 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) sparkercare@aol.com Dharshivi Ltd Manager post vacant Care Home 13 Category(ies) of Learning disability (0) registration, with number of places Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 13. Date of last inspection 3rd July 2007 Brief Description of the Service: The home provides care and accommodation for up to 13 people with learning disabilities. Service users have single bedrooms, on 3 floors (not served by a lift). Twenty-four hour care is provided. The home is in the centre of town with good access to local amenities. There is a small patio area at the rear and a large car park. The range of fees charged for services provided range from £518 to £545 per person per week. Mariners Folly DS0000050495.V365444.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 inspection took place at 9:00AM on 7th August 2008. The Inspector agreed and explained the inspection process with the Manager. The focus of the inspection was to assess Mariners Folly in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider/manager was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home has completed an annual quality assurance assessment questionnaire (AQAA), which was received on time. This provided the Inspector with information relating to What the agency considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORA’s and AQAA’s. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, rota’s, training records and recruitment records. In addition an environmental tour took place. The Inspector identified several residents for case tracking. In addition the inspector had the opportunity to speak with several of the residents and a number of staff. Additional evidence was gained to inform judgements following the observation of many of the residents and their interactions with staff. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? It was evident through the inspection process that the manager is taking appropriate steps to continually review and improves the standards of care within the home. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 7 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. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can be confident that their needs will be properly assessed prior to moving to the home. Prospective residents also have the benefit of a trial period at the home. EVIDENCE: Records held showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. The residents, their families and health provide the information / social care professionals. This is then reflected into the care plans and these are developed in agreement with the individual where possible. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The assessment process recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The inspector recommended that the home reviews it equalities and Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 10 diversity policy and considers carrying out an equalities impact assessment. This is requested to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. Additionally it was recommended that Equality and Diversity training for all staff including management is considered. Prospective Residents have the benefit of a trial period at Mariners Folly to assess whether the home can or cannot meet their needs. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from having clear individual plans that are comprehensive, identify their needs and are specific to the individual service user. However further evidence that residents are fully involved in the process and contribute towards setting their hopes aspirations and goals needs to be evidenced. Care plans showed that residents are enabled to make decisions and choices. Residents are enabled to take responsible risks through a thorough risk assessment process. EVIDENCE: The key principles of the home for delivering a quality service are based on the belief that residents should be able to take control of their lives. The staff of the home are strongly committed to supporting all residents including those with limited communication or intellectual skills to make informed decisions, Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 12 understand the range of options which are available to them and have the right to take responsible risks. The home and its staff are committed to supporting the residents in accordance with their needs and goals. This was evidenced through the care plans, which detailed the areas of support that the resident needed and how this support is provided by the staff. There were clear guidelines in respect to routines and supporting the residents with their needs. The manager confirmed that these are reviewed with healthcare professionals, relatives and residents where possible on a regular basis. The inspector viewed a sample of three care plans. The plan focuses on current need. However development of skills, and future aspirations of the individual could be expanded upon. The plans of care generally follow the principles of person centred planning. Staff have the necessary skills to support and encourage the individual to be fully involved. Resident’s rights to make decisions are respected and the care plans reflected their ability to make an informed judgement where possible. Care plans included information concerning the preferred lifestyle and choices. The inspector visited the home at 9:00AM. During the inspection the Inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. The inspector found that the home has a genuine commitment in evolving the resident in the day-to-day running of the home. Staff were responsive and receptive to the residents input. Examples of such included choosing activities and planning of the day ahead. There were guidelines in respect to routines and behaviour. The member of staff confirmed that these are reviewed with the residents on a regular basis and the families are supported to be involved. The inspector requested that care planning is reviewed to further evidence that residents are fully involved in the process and contribute towards setting their hopes aspirations and goals. Care plans include a comprehensive risk assessment. Management of risk takes into account the specialist needs and age of people who use the service, balanced with their aspirations for independence, choice and normal living. Where there are limitations on choice or facilities, it is in the person’s best interest. The resident understands and agrees the limitations where possible. Any limitations are fully documented and reviewed on a regular basis to ensure their ongoing relevance. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 13 Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are offered a range of opportunities for personal development and to learn new skills and feel part of the wider community. Residents engage in a good level of activities, which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The resident’s benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 15 Residents are enabled to participate and contribute to meeting their own selfcare needs and day-to-day chores around the house as their capacity allows. Discussion with staff confirmed that the level of activities were of a good level and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. The management of the home is planning to facilitate a holiday for all the residents to Butlins in Bognor Regis. All the residents and staff spoken were excited about the planned holiday and looking forward to it.The home is to be commended on arranging this holiday, which exceeds the National Minimum Standards. The inspector joined residents at 9:00am while they were getting ready for the day ahead. The inspector had the opportunity to speak to several of the residents who expressed their opinion of the home and the activities they participated in and enjoyed. Other residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities. The service actively encourages and provides imaginative and varied opportunities for residents to develop and maintain social, emotional, communication and independent living skills at Mariners Folly. The staff have a strong ethos and focuses on involving residents in all areas of their life, and actively promotes the rights of individuals to make informed choices, providing links to specialist support when needed. Evidence of this was observed from direct observation and discussions with staff, residents and management. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. Residents were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents’ activities and schedules. Residents are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others with staff support should they wish. Residents on evidence seen have had been involved in planning and choosing what to eat where possible. One service user explained the menus to the inspector and how his choice and preferences influenced the menu. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents feel supported by the level of help given and that their healthcare needs are addressed. The resident can feel confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. However this could be further improved with more detailed guidance for administering as required medication. EVIDENCE: The care plans fully documented the personal support required for individual Residents within Mariners Folly. They reflected their choices and preferences and staff were observed offering guidance where needed. Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different residents daily routines. All residents are allocated a key worker and the inspector observed excellent interaction between staff and residents. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 17 Staff understand the key principles of giving personal support and are responsive to the varied and individual requirements of the residents. When ever possible residents are able to have choice about who delivers their personal care. Where possible Residents are supported and helped to be independent and responsible for their own personal hygiene and personal care. The care plans fully documented all physical and emotional healthcare needs and where able residents filled in or were supported to fill in appropriate forms. Within the care plans records of health care provided by G.P, chiropodist, dentist, and opticians were evident. It is evident through records that the emotional health support is of a high priority to this home and the staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication within Mariners Folly. The manager confirmed that all staff that dispense medication have received the appropriate training. The inspector requested that the need to write up the MAR sheet is reduced to an absolute minimum. If it was necessary in limited circumstances (following a private consultation between the service user and the Doctor) to add items to the sheet, that it is checked and verified by two members of staff. The MAR sheets (drug record sheets) were being completed properly. Doses were not missed and the MAR sheet were able to indicate a reason for missing the dose. The medication file / MAR sheets did have a signature list to evidence who gave the medication signed for on the MAR sheet. The home ensures that the temperature of the medication is monitored on a daily basis. The home has a very limited amount of Prn or as required medication, however protocols were not written up. The home could not demonstrate that as required medication is given following an agreed protocol or reference to the service users care plan. This should state when and how and under what circumstances any Prn medication is given. No statutory requirements have been made at this time. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents and their relatives know that their concerns and complaints are taken seriously and are on the whole protected from the risks of abuse. EVIDENCE: A copy of Mariners Folly complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. The home made the complaints procedure more widely distributed, and highly visible within the service and is available in different formats. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. The home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for the majority of staff. The manager was responsive to the Inspectors comments and has made an undertaking to ensure all staff have the required training as a top priority. No statutory requirement has been made at this time, as the Inspector is confident that such undertaking will be actioned. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 19 The home promotes an open culture where Residents feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding protection are in place. Criminal Record Bureau Checks (CRB) have been obtained for all staff. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s do not wholly benefit from living in a well-decorated environment, which is well maintained. Standards of cleanliness and hygiene were seen to be of a good standard EVIDENCE: The manager stated that the home meets with the requirements of both Fire and Environmental Health Departments; the inspector saw evidence of this. The standard of internal decoration and fixtures and fittings were seen to be of a variable quality. Various parts of the home in the opinion of the inspector where in need of refurbishment, in decoration and the repair / replacement of fixtures and fittings. The manager was requested to formulate an action plan of maintenance and decoration with timescales that meet the requirements within this report. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 21 The premises are kept clean, hygienic throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 22 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 adequate This judgement has been made using available evidence including a visit to this service. Residents’ care, social and emotional needs are promoted by the employment of caring and suitably trained staff overall in such numbers to support their needs. However shortfall were noted with regard to updates to core training for all staff and training for night staff. Residents are protected from potential abuse by the home’s robust staff recruitment procedures. EVIDENCE: From discussions with the Manager, observations and reviewing the staff rotas more than sufficient staff were on duty at the time of inspection to meet the residents needs. The inspector was informed that staffing numbers would be reviewed and staff increased should the needs of the service users change long term. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 23 Home has a housekeeper that works for 16 hours per week. Some cleaning duties are also part of the waking night duties. The staff training records indicated planned and undertaken training. The manager evidenced that individual and group staff training needs had been identified. A range of training has been identified for all staff. The manager confirmed that the induction programme adopted complies fully with the recommendations of the Skills for Care Councils current guidance. First Aid, Food Hygiene, Health and Safety and other core courses are undertaken for the majority of staff to maintain current qualifications and for protection of residents. However shortfalls were noted with regard to shortfalls for a number of staff with regard to updates to core training. This was seen as a concern particularly as it was evidenced that night staff and staff do not wholly benefit from the required training. The manager stated that this would be addressed as a priority. The inspector viewed details of the Home’s recruitment procedure and a number of records relating to staff members recruited. The Home undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of I.D and copies of qualification certificates, seeks written references. However it was requested that references are verified to ensure all reasonable steps are taken to ensure their authenticity. All staff appointments are subject to a probation period, which is subject to review. All staff have a contract of employment and job description. From documentary evidence seen with the majority of staff completing basic courses and over the required minimum 50 of the staff achieving a NVQ (National Vocational Qualification) Level 2 or above care qualification. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 24 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. Resident’s benefit from living in a overall well run and managed home. Residents and or their relatives can be fully confidant that their views and opinions effect how the home is run and that their best interest are safeguarded overall by appropriate policies and procedures. Residents can always feel fully confident that their health and safety/ welfare is protected by robust policies/ procedures and safety checks. EVIDENCE: Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 25 The manager is actively involved in the day-to-day management of the home and works with staff and residents. However at present she is not registered with the Commission. This was seen as a shortfall. The manager stated her intention to register as soon as possible. From observation and staff feedback the manager offers a clear sense of direction and leadership, which staff and residents understand. Residents, their relatives and staff are encouraged to comment on the services the home offers and to voice any concerns they may have. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. Quality assurance was discussed and the views and opinions of many of the residents and stakeholders sought. The residents spoken with confirmed a great deal of satisfaction living within the home and felt confident that both staff and management valued their views and opinions. The manager confirmed that the home does undertake quality assurance by means of asking residents to complete questionnaires. The home operates a keyworker system to identify an individual staff member to directly to work with a service user on a one to one basis. The home has a quality assurance system. The registered provider of the home does regularly visit the home and complete what is known as a Regulation 26 visit. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. However the quality of such Regulation 26 visits viewed were seen to be not very comprehensive in the view of the inspector. The visits need to focus more on outcomes for residents with regard to quality of care, staffing, adult protection, recruitment, audits of policies and procedures and that they are followed, staff training, activities, health and safety etc. No statutory requirement has been made at this time. The home has a full range of policies and procedures to promote and protect Residents’ health and safety. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The manager however needs to ensure all staff are trained in health and safety matters and have regular planned updates. Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 x 33 x 34 3 35 2 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 Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23(2)(b) Requirement 23.—(2)(b) The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. 18.— (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (c) ensure that the persons employed by the registered person to work at the care home receive— (i) training appropriate to the work they are to perform. Timescale for action 07/02/09 3 YA35 18(1)(ci) 07/02/09 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 Mariners Folly DS0000050495.V365444.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mariners Folly DS0000050495.V365444.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. 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