Inspection on 02/08/07 for Conifers

This inspection was carried out on 2nd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Conifers 25/07/08

Conifers 21/06/06

Conifers 02/12/05

Conifers 23/08/05

Conifers 11/10/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Conifers 73 Reculver Road Herne Bay Kent CT6 6LQ Lead Inspector Mark Hemmings – Allocated Inspector Sandra Crosby Key Unannounced Inspection 02nd August 2007 09:15 Conifers DS0000059959.V345406.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 Conifers DS0000059959.V345406.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. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Conifers Address 73 Reculver Road Herne Bay Kent CT6 6LQ 01227 372112 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) skejiou@toucansurf.com Mr Serge Kejiou Mrs Swastee Kejiou Mr Serge Kejiou Care Home 10 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (9), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (6) Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MD (E) is restricted to those persons whose dates of birth are:26.04.1937 19.01.1931 15.12.1926 18.03.1935 17.01.1934 10.07.1931 19th February 2007 Date of last inspection Brief Description of the Service: The home is a detached property set over two floors providing single accommodation for nine adult who have or who have had difficulties with maintaining aspects of their mental health. One of the service users has a learning disability. Of the overall number of service users in residence, up to six may be older people. The facilities provided are single bedroom accommodation, and the shared communal space consists of two lounges one for non-smokers and one for smokers. There are also available bath and walk in shower facilities. The home is located in the village of Beltinge. There are local shops within walking distance, and the coastal town of Herne Bay with its seaside attractions and amenities is a bus ride away, or approximately thirty minutes walking distance. The Registered Providers are Mr S Kejiou and Mrs S Kejiou. Mr Kejiou has assumed responsibility for the day to day supervision of the Home. It was with him that the Inspector worked during the course of the inspection visit. As appropriate in this Report, Mr Kejiou is referred to as being the Registered Manager. The Registered Providers have informed the Commission that the current range of fees they charge for residence in Conifers ranges from £343.90 to £495.00 per week. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection visit was unannounced and carried out on Thursday 02 August 2007 between 09.15 and 13.00. The Inspector spoke with the Registered Manager who is also one of the Registered Providers, the one support worker that was on duty and several service users. Various records were viewed and an accompanied tour of some areas of the premises was undertaken. The length of the inspection visit was adjusted in order to allow for the fact that there was only the Registered Manager and one support worker on duty at the home at the time of the visit. The AQAA documentation that homes are required to complete was only recently sent to the home, so information that would normally be used to inform the inspection process was not available to be included in this inspection report. Due to the short notice given to plan the visit, although Service User Surveys and Relative Surveys have been sent out, a number of these have not been returned in time for the comments to be included in this report. Seven Service User surveys and one relative’s survey were returned completed and received by the Inspector on the 06 August 2007, mainly all providing positive comments about the home for example ‘I am very glad that I did come here’, ‘the staff are very good’, ‘plenty of leeway is allowed whenever possible’ and ‘there are keyworkers here that I can talk to’. Since the last key inspection visit dated 04 July 2006, one complaint has been received and a Random inspection visit dated 19 February 2007 was undertaken and the outcome of that visit concluded that no significant items remained outstanding in relation to the complaint. The Registered Provider, the Manager, the management team, and staff are working hard and committed to meeting the requirements of regulation. What the service does well: Service users said that the Home provides them with a relaxed and generally comfortable setting within which to make their home. They observed that they receive all the assistance they need. Also, they said that the support workers are attentive and kind in their manner. The garden area is well maintained, and service users commented that they liked to use this area weather permitting. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 6 It was noted that the service users are consulted about relevant aspects of how their home is run. What has improved since the last inspection? What they could do better: Review the Statement of Purpose and Service User Guide for the home. Pre-Assessment information to be comprehensive and the documentation signed and dated. Undertake regular review of the Service User Plans. Record all appropriate risk assessments. Make suitable arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines. Ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. Staff to undertake training in relation to Adult Protection. Staff to commence National Vocational Qualifications. Please contact the provider for advice of actions taken in response to this Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 7 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. Conifers DS0000059959.V345406.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 Conifers DS0000059959.V345406.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): Standards 1,2 and 5 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide provide service users and prospective Service Users with the information they need to make a decision about moving into the home. There are systems in place to ensure that prospective service users and their representatives have their needs assessed. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Statement of Purpose and Service User Guide for the home were seen, and it was found that these documents needed to be reviewed and small amendments made. Pre-assessment documentation was seen for a recently admitted service user. The format of the documentation was comprehensive however several pages had not been completed, and the documentation was not signed and dated. Therefore it was difficult to assess the practical application of the various systems adopted by the Registered Providers to establish the suitability of the home for prospective service users. However. It was indicated that the Registered Manager is aware of the need to give this matter careful consideration. This is so that a new service user’s needs for support can be met reliably from the start of their period of residence. The Registered Manager was observed to be familiar with the principal subjects to be considered. At the last key inspection the Registered Manager said that he informs support workers about the needs of new service users by asking them to read the information he has collected. Also, that they are asked to review information received from the relevant care manager (social worker). In addition to this, he said that he briefs support workers orally so that they can clarify any points of detail as may be necessary. The support workers confirmed this account and they said that they consider themselves to have been informed adequately about the needs of service users admitted in the past. Service users are provided with a contract/terms and conditions of residence. Conifers DS0000059959.V345406.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): Standards 6,7 and 9 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care which service users receive, is based upon their individual needs and is appropriate. The principles of respect, dignity and privacy are put into practice. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 12 EVIDENCE: It was noted that there are various systems in place to enable each service user to liaise with support workers in order to identify and to plan for the provision of the assistance they need. These measures include the preparation for each person of a written individual plan of care. The service users said that they had been involved adequately in the preparation of their individual plans and also that they had been invited to contribute to their occasional review. Three Service User Plans were examined, and it was found that there was insufficient detail in the care planning section and did not address all assessed needs. Reviews are carried out but not always on a regular basis. Appropriate risk assessments were not seen as part of the service user plan. It was noted on the whole that the daily records were comprehensive. The Registered Manager agreed to address the issues raised. Due to the staffing shortage on the day of the visit, the Inspector was able to only spend a short time speaking with the one support worker on duty. It was however stated in the last key inspection report that the Inspector spoke with support workers about various elements of the support provided for some of the service users. They were noted to have an adequate knowledge of the material in question. The Inspector observed episodes when they assisted some of the service users. Their practice was noted to be appropriate and to be consistent broadly with the Registered Providers’ assessment of the needs to be met. The Registered Manager said that none of the service users are assisted directly by him to administer their financial affairs. Records are maintained of monies handled by the Registered Manager, and service users sign for monies received. What assistance they do receive, is provided by family and by advocates. It is a good idea to keep these functions separate like this, so that registered providers do get involved in more areas of a service user’s life than is necessary. For one service user the Registered Manager has been asked to retain and disburse his weekly personal spending allowance. The Inspector examined the records of the various transactions in question and found things to be in order. The service user said that he remains satisfied with the arrangement. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17 were inspected at this inspection visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able generally to choose their life style, social activities and to keep in touch with family and friends. Service users receive a healthy and varied diet according to their requirements and choice. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 14 EVIDENCE: Most of the service users undertake a range of activities each week, some of which have an explicit vocational element. The service users that spoke with the Inspector about this matter said that they are satisfied in general with their respective calendars of activities. The Registered Manager said that for each of the service users there is a written calendar that lists the commitments they have chosen to attend most weeks. These calendars were seen, and the Registered Manager confirmed that changes had been made following the last key inspection visit. It was noted that most of the service users leave the home regularly in order to do various things such as going to shops and visiting friends. The service users said that they are satisfied with the degree to which they can access the local community if they wish to do so. The service users said that support workers assist them to keep in touch with members of their families. This includes helping them to use the telephone and to engage in written correspondence. The service users said that the support workers are kind and approachable in their manner. Also, they observed that support workers are not intrusive and that they respect their needs for private space. It was reported in the last key inspection report that during the course of the inspection visit, the Inspector had the opportunity to observe a number of instances when support workers interacted with service users. It was noted that these events are characterised by a quiet but confident informality. It is recognised that this constitutes good care practice. This is because it acknowledges service users’ simultaneous needs both for independence and for support. The service users said that they are provided with suitable meals. On the day of the visit ‘choices’ was on the menu, and the Inspector was told that the service users were able to choose a microwavable meal of their choice. One service said that they had asked for a prawn curry, and another service user said that they had asked for a roast beef dinner. One service user was seen to have soup and sandwiches in the garden area as he said that he had already eaten a meal out earlier in the morning. The meal time itself was a relaxed affair with service users dining at their own pace. There was no sense of them being rushed or overly organised. The record of food provided in the home was consistent with the Registered Manager’s account to the effect that the service users are offered the opportunity to have a normally balanced diet. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ emotional, physical and health care needs are met. Service users are in the main assisted to take medicines in the correct manner. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 16 EVIDENCE: The service users said that the pace of daily life in the Home is relaxed without there being any unnecessary rules to disturb their experience of a normal domestic setting. They observed that within reason, they can decide on the pattern of their day. They spoke about things such as them being free to decide when to retire to their bedroom and choosing what clothes to wear. The Registered Manager said that the support workers keep a tactful eye open so that service users can be assisted to seek and to follow medical advice should it be needed. One service user is assisted to keep regular appointments with the District Nurse, and another service user was being assisted in the keeping of hospital appointments. It was noted that the Commission has not received since the last inspection visit, any expressions of concern from the local primary health care team about its working relationship with the home. All of the service users have elected to have support workers retain and dispense most of their medications. This it is indicated is a sensible arrangement given the interests of the people concerned. The medication records were examined, and it was found that the breakfast medications had all be administered and the records not signed. It was also discussed that written changes had been made to several medications, and it was not documented as to who had authorised the change and when. It was seen that one service user was taking her early medication at 10.45 and the Support Worker said that the service user usually takes her medication at the appropriate time. The Registered Manager agreed to address these issues. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have an effective complaints procedure and they are protected from abuse. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 18 EVIDENCE: There is a complaints procedure that explains how service users and other stakeholders can make a complaint about any aspect of the facilities and services provided in the home. Service users said that they are confident that any matter they raise will receive serious attention and that if possible they will be addressed. The Registered Manager said that the Registered Providers operate various systems that enable all complaints to be investigated promptly and fully. The address of the Commission seen in the complaints information needs to be updated, and the Registered Manager agreed to do this. The one complaint received since the last key inspection visit has been appropriately dealt with and the Commission has not received any expressions of concern from the various local mental health services about any aspect of their working relationships with the home. The Registered Manager said that staff had not undertaken adult protection training as yet, but was to be incorporated into planning training for staff. The service users said that they feel safe living in Conifers. They observed that they are confident that support workers will act in their best interests. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,29 and 30 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical layout of the Home enables service users to live in a generally well-maintained and comfortable environment, which promotes independence. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 20 EVIDENCE: Service users said that they are comfortable living in Conifers. It was seen from the accompanied tour of some areas of the home that in general the accommodation was welcoming and pleasant. The Registered Manager said that re-decoration is ongoing and some areas remain in need of upgrading. The Registered Manager said at the last key inspection visit, that none of the service users currently in residence, experience any significant difficulties with getting about the home. More generally, the Registered Manager said that the Registered Providers are aware of the need to keep the subject of service users’ mobility under active review. This is because the premises have not really been designed around the mobility needs of the older people in residence. It is noted that the home complies currently with the principal requirements of the local Department of Environmental Health. This means that the kitchen is equipped and used appropriately. The service users said that support workers assist them to put their clothes in the washing machine, to dry them and to iron them. It was noted that the service users were dressed appropriately in clean clothes of their own choice. The laundry facilities are adequate given the size of the home and meet the needs of the current group of service users. The Fire Log Book was seen and indicated that the appropriate regular monitoring checks are carried out. The electrical certificate for the home was seen together with the PAT testing certificate that is due for renewal in the near future. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are assisted by support workers, who are appropriate people and on the whole suitably skilled. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 22 EVIDENCE: At the time of the inspection visit the staff at the home consisted of the Registered Manager and one support worker. The Registered Manager said that there are usually two support workers on duty during the day, that he was in the process of employing staff, but had been let down. The support workers also cover domestic/laundry/cooking duties. It was indicated that from 17.00 hours there was only one support worker on duty. The staffing levels at the home were discussed with the Registered Manager and he agreed to address the current situation as quickly as possible. The Registered Manager said that one of the current four support workers had acquired a National Vocational Award in health and social care. This Award is designed specifically to offer support workers the opportunity to confirm elements of good practice and to extend the range of relevant skills at their command. The Registered Manager said that all newly appointed support workers would be encouraged and helped to study for the Award. This commitment is welcomed, while acknowledging that some of the existing members of staff do not at present want to work towards the qualification. The Registered Manager said that the Registered Providers complete all of the checks specified in the Regulations. However, this could not be verified as there had been no new appointments made since the last inspection visit. The checks in question are important. This is because they are one of the means by which the Registered Providers can ensure that only suitable people are trusted to have unsupervised access to service users who may be vulnerable. The Registered Providers deliver introductory training for all new support workers. This is done to ensure that they have the skills and knowledge they need in order to work without direct supervision. This is important because the competencies possessed by support workers, largely determine how well they are able to assist service users. The Registered manager confirmed that the training system had been strengthened by the adoption of a new national model that the Commission recognises to represent good practice. However, in the absence of any new appointments since the last site visit, no judgement could be made. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 23 The Registered Manager said that he meets informally with each of the support workers in order to review their work and to sort out any problems, should there be any. This is important because support workers need to have the opportunity to reflect upon their work and to work towards resolving the problems that will crop up inevitably. The support workers said that they consider themselves to be free to speak with the Registered Manager, who they think is helpful and knowledgeable about residential care provision. Although the supervision sessions are not undertaken on a two monthly basis as yet, the Registered Manager confirmed that written records are now maintained. Conifers DS0000059959.V345406.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): Standards 37,39 and 42 were inspected at this inspection visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The promotion of health and safety is effective generally. There is a quality assurance system in place. Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 25 EVIDENCE: Service users may benefit from a well run home, however on the day of the inspection visit there were insufficient staff on duty and the Registered Manager was unable to address this issue. It was noted that the Registered Manager continues on the whole to administer the Home in an appropriate manner, so as to help the support workers to coordinate their efforts in a reliable manner. This is very important because it means that service users can experience consistent support regardless of who happens to be on duty in the Home. The Registered Manager has acquired formal qualifications that the Commission recognises as confirming his possession of competencies that are key to effective management. As noted earlier in this Report, the service users said that the support workers consult them about various aspects of the day to day running of the Home. It was discussed that the Registered Providers complement this largely informal arrangement, by asking service users to complete an annual questionnaire. The results of this exercise are then summarised in a Quality Report that is available for service users to consult and upon which they can comment. The Registered Manager said that the Registered Providers are going to consider further what additional methods can be used to consult with service users. This is a good idea because questionnaires tend to not be popular and so often do not get completed fully. The Registered Providers were noted to have completed the various routine checks that have to be undertaken to ensure the continued operability of the Home’s fire safety equipment. Also, they operate a system which is designed to ensure that all of the support workers know how best to avoid the occurrence of a fire safety emergency and how to respond to one should the need arise. This is very important because the actions taken by staff determine largely the level of fire safety protection available in the Home. Conifers DS0000059959.V345406.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 2 2 X 3 2 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 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 2 X 3 X X 3 X Conifers DS0000059959.V345406.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 YA1 Regulation 6 Requirement Timescale for action 31/08/07 2. YA3 14 The registered person shall (a) keep under review and where appropriate revise the statement of purpose and the service user guide and (b) notify the Commission and service users of any such revision within 28 days The registered person can 31/08/07 demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home 3. 4. YA6 YA9 Record appropriate comprehensive pre-assessment information necessary to inform the initial service user plan 15(2) The registered person shall (b) 31/08/07 keep the service users plan under review 13(2)(4)(c) Staff enable service users to 31/08/07 take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the DS0000059959.V345406.R01.S.doc Version 5.2 Page 28 Conifers 5. YA20 13(2) 6. YA23 13(2)(6) home’s risk assessment and risk management strategies. The registered person shall 04/08/07 make arrangements for the recording handling safekeeping safe administration and disposal of medicines received into the care home The registered person ensures 31/12/07 that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy Staff to undertake training in relation to Adult Protection Staff have the competencies 31/12/07 and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required time-scales. The home has an effective staff 04/08/07 team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. 7. YA32 18(1)(a) 8. YA33 18(1)(a) 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 Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 29 Conifers DS0000059959.V345406.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Local 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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