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Inspection on 23/08/05 for Conifers

Also see our care home review for Conifers for more information

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The assistance each service user receives is provided in consultation with them and takes place within a prudent assessment of potential risks to the person`s health and safety. A suitable balance has been achieved between engaging service users in everyday activities and respecting their need for private space and for quietness. The support workers are able to demonstrate their possession of a number of competencies which are relevant to the effective provision of assistance for the service users in residence. The Home`s catering service is well organised and service users consider the food served to be enjoyable and sufficient.

What has improved since the last inspection?

The Registered Providers have redecorated a number of the bedrooms and some of the communal areas. A number of the administrative systems used in the Home have been strengthened. These should better enable support workers to coordinate their efforts so as to ensure that the service users receive a consistent response to their needs.

What the care home could do better:

There was a category of omissions in the records which have to be kept of each occasion on which support workers dispense medicines to service users. It is important that these records are kept accurately at all times because they help to ensure that each service user receives the medicines which have been prescribed for them. There were omissions in a class of the security checks which have to be completed in relation to new support workers. The completion of these checks is significant because they are one of the means used to ensure that only appropriate people are entrusted to have unsupervised access to service users. A particular aspect of the fire safety regime needs to be strengthened further.

CARE HOME ADULTS 18-65 Conifers 73 Reculver Road Herne Bay Kent CT6 6LQ Lead Inspector Mark Hemmings Announced 23/08/05 at 10:00am 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 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 Stationary 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 H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Conifers Address 73 Reculver Road, Herne Bay, Kent, CT6 6LQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01227 372112 Mr Serge Kejiou Mr Serge Kejiou Registered Care Home 10 Category(ies) of Mental Disorder registration, with number of places Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Home is registered to provide accommodation and personal care for 10 adults who have or who have had difficulties with maintainin aspects of their mental health. One of the service users is recognised as also experiencing a learning disability. Of the overall number of service users in residence, up to six may be older people. 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. Date of last inspection 11.10.2004. Brief Description of the Service: The premises are a detached two-storey older property which has been adapted for its present use. There is provision for all of the service users to have their own bedroom. All of the bedrooms have a washhandbasin and five of them have a private toilet. One of them also has a private shower. There is a call bell system which is designed to assist service users to summon assistance should it be needed. The property is set back a little from a main road. To the rear of the Home, there is quite an attractive enclosed garden. The nearest parade of shops is within reasonable walking distance. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was announced and it took about nine hours to complete. During this time, the Inspector spoke with or spent time with six service users. Also, he spoke with the Registered Manager. The Inspector examined various records and he spoke with two of the support workers. The Inspector looked at various parts of the accommodation. This included (by invitation) one service user’s bedroom. The Home continues to provide the service users in residence with the support and assistance they need. Service users say that they remain satisfied with the provision made for them in Conifers. There are six required developments at the end of this Report. What the service does well: What has improved since the last inspection? Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 6 The Registered Providers have redecorated a number of the bedrooms and some of the communal areas. A number of the administrative systems used in the Home have been strengthened. These should better enable support workers to coordinate their efforts so as to ensure that the service users receive a consistent response to their needs. 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. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. Prospective service users are given the information they need to make an informed decision about living in the Home. Service users’ needs and aspirations are assessed before they move into the Home. Service users are confident that the Home will enable their needs for assistance and support to be met. Prospective service users have the opportunity to visit the Home before deciding about moving in. Each service user has a written account of their terms and conditions of residency. EVIDENCE: There is a Service Users’ Guide. This is a brochure which prospective service users are given and which outlines the facilities and services provided in Conifers. In addition to this, the Registered Manager speaks with prospective service users to answer any remaining questions they may have. The Registered Manager meets with each prospective service user to assess their needs for assistance. This is done to ensure that these needs can be met reliably in the Home, should the admission proceed. Service users say that they were confident at the point of admission to the Home, that they knew what was on offer and that this would meet their needs. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 9 Also, they observed that their expectations of the services they hoped to receive, have been met in full. Service users say that they were encouraged to visit the Home at least once before they made a decision to move in. They consider this to have been useful because it gave them a first hand impression of what daily life in Conifers is really like. All of the service users have a copy of the contract of residence. This document gives a suitably detailed account of the terms and conditions in accordance with which the Registered Providers deliver accommodation and care services in the Home. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 and 10. Service users are confident that their present and future needs for personal care will be met in a reliable and consistent manner. They are suitably consulted about both the assistance they receive and the day to day running of the Home. Service users are supported in taking prudent risks. Service users know that information about them is handled in a confidential manner. EVIDENCE: There is a service user plan for each service user. These documents describe the assistance the service user in question has agreed to receive. The Inspector sample checked several of these plans and he found them generally to be suitably detailed. However, in relation to Service User A there was a category of omissions. The Registered Providers should correct this oversight within the time scale listed in the relevant Required Development at the end of this Report. Service users say that they are consulted about the contents of the plans and that they are invited to contribute to any reviews which are convened. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 11 Service users consider that they receive all the assistance they need. Support workers assist service users in a manner consistent with that described in the individual service user plans. Service users are assisted to take those reasonable risks which are part of everyday living. The Registered Manager is aware of the need to keep this matter under continuous review. This is so that service users are assisted to avoid situations in which their own welfare or those of others may become jeopardised. Service users say that private information about them is treated as being confidential. Support workers have a good understanding of how to ensure confidentiality in practice. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Service users have access to a suitably varied range of social and vocational activities. Some of these involve engagement with the local community. Service users are assisted to maintain contacts with family and friends. Service users are enabled to exercise their citizenship rights and to respect those of other people. Service users are offered a suitably healthy diet. EVIDENCE: Service users undertake a range of social and vocational activities. Service users say that they are consulted about what they want to do and that staff assist them to access the necessary resources. The Inspector witnessed a several of these events taking place during the course of the inspection visit. Most of these involved service users leaving the Home in order to attend activities in the community. Service users consider their time to be appropriately occupied. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 13 The Registered Manager and the support workers are aware of the need to strike an appropriate balance between engaging with service users and recognising their needs for quiet time. This is an essential element of good practice within the Home. Service users are assisted to maintain helpful contacts with members of their families and with friends who do not live in the Home. Service users say that they are provided with good quality meals and that they always have enough to eat. The Inspector took lunch with service users. He noted the meals served to be of a good standard and to be adequate in quantity. The written menu indicates that the service users are offered a normally balanced diet. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. Service users receive assistance and support in a respectful and appropriate manner. Service users’ physical and emotional health care needs are met. Service users are assisted to handle their own medication, when this is appropriate. As necessary, there are generally suitable arrangements in place to enable staff to retain and dispense medication on behalf of service users. EVIDENCE: Service users say that support workers are attentive to their needs without being intrusive. The Inspector witnessed a large number of occasions on which support workers assisted service users. He noted these events to be characterised by a quiet informality which is consistent with good care practice. Service users who have problems with aspects of their physical health are assisted to seek and to follow the advice of their doctor. Staff keep a tactful eye open so that medical conditions are noted at an early point. The Commission has not received any expressions of concern in relation to the Home, from partner agencies such as members of the primary health care team. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 15 On a risk assessed basis, service users are assisted to manage their own medication. At the time of the inspection, none of the service users were acting in this capacity. The Inspector examined selected aspects of the arrangements used by staff to administer service users’ medication. He found that suitable practices were in place to store medicines and to ensure that service users take them in the manner intended by their doctor. However, there was a category of omissions in the records which should be kept of each occasion on which a medicine is dispensed to a service user. Also, there were omissions in the level of written detail provided to support workers when dispensing a discretionary medicine to Service User B. These oversights are listed for correction in the relevant Required Developments at the end of this Report. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Service users consider that their views are listened to and that as necessary they are acted upon. Service users are protected from abuse, neglect and self harm. EVIDENCE: There is a complaints procedure which 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 say that they are confident that any matter they raise will receive serious attention and if possible will be addressed. The Inspector notes that neither the Registered Providers nor the Commission is in receipt of any complaints relating to Conifers which remain to be resolved. Support workers have a sound understanding of what constitutes good care practice. As part of this, they are aware of the need to be alert to instances which might jeopardise the well-being of a service user. Also, they are aware of how to bring such a matter to the attention of the Registered Providers and/or to external regulatory bodies. Service users say that they feel safe living in Conifers and that they trust members of staff to act in their best interests. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30. The Home provides comfortable accommodation. Service users’ bedrooms are adequately presented and equipped. There is a sufficient number of toilets and bathrooms. There are sufficient shared spaces. There is adequate equipment in place to enable support workers to assist those service users who experience a measure of reduced mobility. The Home is cleaned to a normal domestic standard. EVIDENCE: Service users say that their accommodation is homely and that it is familiar to them. The Registered Providers have redecorated a number of rooms since they purchased the Home. The Registered Manager said that this programme of refurbishment will continue to eventually include all parts of the premises occupied by service users. Service users say that they like their bedrooms and that they have all they need in order to use them as bed sitting areas. The Inspector visited one of the Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 18 bedrooms and he noted it to be comfortable and to reflect the preferences of the person in residence. There is an adequate number of toilets and bathrooms, given the needs of the service users presently in residence. Also, there is sufficient provision of lounge and dining space to enable the service users to relax in comfort when not occupying their bedrooms. Although some of the service users are older people, most of the people in residence are able to get about without assistance. There is adequate equipment in place to enable support workers to assist safely those few service users who do experience a measure of reduced mobility. The accommodation is cleaned to a normal domestic standard. The Inspector examined the kitchen. He noted it to be presented to a suitable standard of hygiene and that it was operated appropriately. The Inspector understands that the local Department of Environmental Health has not recommended the completion of any improvements which remain outstanding. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. Support workers have a good understanding on their duties and they work together well as a team. There is an adequate number of staff on duty. Support workers have the competencies they need and their practice is monitored. A number of steps are taken to ensure that only suitable people work in the Home. EVIDENCE: Support workers are provided with a written account of their duties. The staff team is relatively stable. This means that people have got used to working together and that service users know who is going to be around and what they are going to be doing. There are handover meetings at the beginning and end of each shift and support workers keep diary records of how things are going for each service user. There are regular staff meetings and support workers say that they are actively consulted by the Registered Manager about how the Home is administered. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 20 There are two support workers on duty during the day. At tea time the evening and night shifts commence. Staff say that enough support workers are deployed in the Home to enable an effective service to be provided. Service users say that support workers are always around when they need them. The Inspector considers the Home to be staffed adequately, given the needs for assistance of the service users currently in residence. The Registered Providers complete a number of security checks in relation to each prospective new support worker. These are carried out in order to better ensure that only suitable people are entrusted to have unsupervised access to service users who may be vulnerable. The Inspector noted there to be a category of omissions in relation to Support Worker A and in relation to Support Worker B. The Registered Providers should correct these errors within the time scale listed in the relevant Required Development at the end of this Report. One of the four support workers has completed a relevant National Vocational Qualification (NVQ) in health and social care. The Registered Manager said that as new support workers are recruited, they will be encouraged to complete the Award. This qualification is designed to validate that individual support workers have the skills they need to respond effectively to service users’ needs for assistance. The Registered Providers ensure that all new support workers receive a period of introductory training before they work with service users without direct supervision. The Registered Manager is going to strengthen the list of subjects covered in this initial training. This development will be completed by 1 October 2005. Some of the support workers have undertaken various courses in subjects relevant to their work. The Registered Manager said that the records of this attendance are not up to date. This matter is going to be resolved as part of a larger development. This will see the Registered Providers completing a thorough audit of the competencies each support worker possesses to provide personal care services in the Home. The Inspector considers this exercise to be particularly important given the only limited number of staff who have completed a relevant National Vocational Qualification. The Registered Providers intend to complete the review by 1 July 2006. The Inspector considers that the support workers have the competencies they need in order to provide a reliable and effective response to the present service users’ needs for assistance. The Registered Manager routinely works alongside the support workers when they are providing assistance to the service users. This enables him to monitor and to give advice to support workers about aspects of their care practice. The support workers consider the Registered Manager to be knowledgeable about Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 21 residential care and to be supportive in his manner. This informal dialogue is now going to be complemented by more organised meetings. These will entail each support worker meeting in private with the Registered Manager to review their work and to resolve any problems should there be any. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41 and 42. The Registered Providers run the Home so as to reliably provide service users with appropriate assistance. The Registered Providers operate a quality assurance system. Service users’ rights and best interests are protected the operation of the Registered Providers’ recording systems and by the implementation of their policies and procedures. In general, the health and safety of service users and staff is adequately protected. EVIDENCE: The Registered Manager has the competencies necessary to enable him to operate the Home in the best interests of the service users. He has acquired a formal qualification in management and he is about to complete the National Vocational Qualification which is prescribed by the Standards for incumbents of his post. The Registered Manager has a detailed understanding of the day to operation of the Home and of the particular needs of each of the service users. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 23 Both the service users and as already noted the members of staff, say that they feel themselves to be free to approach the Registered Manager if there is something troubling them. In addition to these informal consultations, the Registered Providers operate a quality assurance system. This is designed to enable stakeholders in general and service users in particular to comment on the adequacy of the facilities and services available in the Home. The Registered Providers are going to strengthen an aspect of how the results of this annual exercise are notified to service users. This will entail the preparation of a Quality Report. The first of these will be made available by 1 November 2005. The Registered Providers maintain various recording systems to assist in the management of the Home. The Inspector examined the accident book and he noted that there were no patterns which indicated the need for him to make any further enquiries. The Inspector examined the records which the Registered Providers keep in relation to those service users who elect to receive assistance with the management of their weekly personal spending allowance. Most of the various entries checked were found to be in order. However, in relation to Service User A there were omissions in the records of the various transactions involved. The Registered Manager said that this matter will be addressed within the time scale established in the Required Development at the end of this Report. Service users are confident that their monies are administered in an appropriate manner. There are various policies and procedures available in the Home. These are designed to support staff when undertaking their duties. The Inspector noted that support workers are conversant with the principles expressed in these documents. Also noted, was that they carry out their work in a manner which is consistent with their provisions. The Registered Providers complete a regular review of the premises to ensure that there are no significant hazards which might compromise the health and safety of any of the service users. This exercise is now going to be strengthened by including for consideration the need to guard the heated surfaces of radiators and to control the temperature of the hot water service. This exercise will be completed by 1 January 2006. The Registered Providers are going to submit to the Kent Fire Service a written assessment of the adequacy of the fire safety regime operated in the Home. This development will be completed by 1 January 2006. In the interim, the Inspector understands that the Kent Fire Service has not recommended any improvements which remain outstanding. The Registered Manager completes the periodic checks which have to be made to ensure the continued serviceability of the Home’s fire safety regime. This work now needs to be Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 24 strengthened by the introduction of a system which is designed to ensure that all members of staff are competent to respond effectively to a fire safety emergency. The time scale for the completion of this development is described in the relevant Required Development at the end of this Report. The Registered Provider has arranged for all appliances such as gas boilers to be serviced in accordance with the manufacturers’ instructions. Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Conifers Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 2 2 x H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 26 No Are there any outstanding requirements from the last inspection? Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 27 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 6 Regulation 15 Requirement The Registered Providers should in consultation with Service User A correct an omission in the relevant Service User Plan. The Registered Providers should ensure that a suitable record is maintained of each occasion on which a medicine is dispensed to a service user. The Registered Providers should correct omissions in the written information provided to support workers to assist them when dispensing a discretionary medicine for Service User B. The Registered Providers should correct a category of omissions in the security checks which have been completed in relation to Support Worker A and in relation to Support Worker B. The Registered Providers should correct a category of omissions in the records of the transactions made in order to manage the personal spending monies of Service User A. The Registered Providers should ensure that all members of staff are included within a system desgined to validate their competencies to respond effectively to a fire safety emergency. Timescale for action 01.09.05 2. 20 13 24.8.05 3. 20 13 01.10.05 4. 34 19 01.09.05 5. 41 17 24.08.05 6. 42 23 01.10.05 Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 28 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. Refer to Standard None Good Practice Recommendations Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 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 Conifers H56-H05 S59959 Conifers V232020 230805 Stage 4.doc Version 1.40 Page 30 - 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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