Inspection on 13/09/05 for Eastry House

This inspection was carried out on 13th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eastry House 08/01/09

Eastry House 29/01/07

Eastry House 16/05/05

Eastry House 27/01/05

Eastry House 26/07/04

Eastry House 20/01/04

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

CARE HOME ADULTS 18-65 Eastry House High Street Eastry Sandwich. Kent CT13 0HE Lead Inspector Michele Etherton Announced 13/09/05 at 9.45 am 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. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eastry House Address High Street, Eastry, Sandwich, Kent CT13 0HE 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) 01304 619655 01304 621895 Family Care Homes Limited Miss Rosemary Chapman Registered Care Home 22 Category(ies) of Learning Disability registration, with number of places Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Eastry House is a period residence located in the high street of the village of Eastry. The house, accommodates up to 22 adults with a broad range of learning disability and dependency aged from mid 30’s upwards. The house is also home to a number of older people who have moved from long stay institutions. Accommodation is provided in predominantly single bedrooms and the home has actively sought to reduce the number of shared rooms over the last few years, only two shared rooms currently remain. The accommodation is laid out over two floors with two lounges, a dining area and activities room, and a number of bedrooms located on the ground floor. The remaining bedrooms are on the first floor. A programme of upgrading of Eastry house has been ongoing for several years and internal redecoration and refurbishment is ongoing. As a period building there is also a need for regular maintenance of the fabric of the building and this is also ongoing. The overall site benefits from the recent development of a purpose built day centre, for the use of service users of Eastry house and its smaller units, although activities are also organised by staff within the house. The home has a small number of parking bays to the side of the property, however, parking is available in surrounding streets and a nearby carpark. There is a local bus service to surrounding towns, and the village has a small number of shops, including a post office and two public houses. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place in one day over 6.30 hours, during which the remaining key inspection standards were assessed, and progress made by the home in achieving outstanding requirements and recommendations highlighted at the last inspection was reviewed. A tour of the premises was undertaken which incorporated the assessment of some bedrooms and bathrooms where outstanding environment works had been identified previously. Communal areas were also viewed during this visit. A number of the current service user group were at the day centre or away on holiday at the time of this visit, however, the inspector observed eight service users during this visit and spoke with five of those, some in more depth than others dependent on their ability. An excellent ratio of care and domestic staff were in evidence on this visit. The inspector spoke with one of the providers, and the home manager, in addition to the home team leader. Four other care staff were also spoken with and observed during this visit. Two comment cards and a letter were received from relatives of service users giving very positive feedback about the service. Unfortunately, no responses have been received to date from health or social care professionals to inform this inspection. What the service does well: What has improved since the last inspection? Eastry House has taken on board medication requirements issued by the pharmacy inspector in respect of two smaller units on site which could also be relevant to the practice at Eastry House, and have amended medication procedures accordingly, they have also addressed good practice recommendations made which were also equally relevant to the house staff. A concerted effort has been made by the home to address shortfalls in the recruitment files. The service user guide and statement of Purpose have been amended to reflect the recent changes to the registration, and the separate identity of Eastry House in its own right. The Home has actively taken on board previous criticisms in respect of failing to adequately consult both with service users and other stakeholders and has implemented a series of measures to improve involvement of users, and engage with relatives and care Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 6 managers more in the agreement of care plans, behaviour strategies and quality assurance of the service. 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. Eastry House H56-H05 S23387 Eastry House V242707 270905 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 Eastry House H56-H05 S23387 Eastry House V242707 270905 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 The Home has a Statement of Purpose and service user guide that informs both existing and prospective service users about the service offered. The Home has an assessment procedure to ensure prospective service users needs can be adequately met by the Home. EVIDENCE: In view of changes to the registration of Eastry house earlier this year, a revised Statement of purpose and user guide were required to reflect the individual services provided by the house as opposed to some of its satellite units. Both documents have now been updated and service users have contributed to the user guide by providing user comments. Although not able to fully re-assess standard 2 because the home is not currently assessing any prospective service users, the process was discussed The discussion highlighted that the assessment process is conducted in a manner that allows adequate time for assessment and introductory visits to take place at the service users own pace, and for supporting documentation and interviews with other relevant stakeholders to be conducted. Initial referrals are made to the client care department who undertake preliminary enquiries and introductory visits to prospective users before more in depth assessment is undertaken. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 9 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 The Home have improved opportunities for service users to be consulted about their care and support needs and as a result influence their care plans. EVIDENCE: The Home have made significant progress to address an outstanding requirement of several previous inspections. This highlighted the need for wider consultation to take place, with service users and other stakeholders in respect of care plans and behaviour management strategies. Care plans are now routinely forwarded to care managers and other interested parties e.g relatives for agreement and approval, these stakeholders are asked to return a signing off sheet to the home to confirm they have received and agree the care plan. Nineteen of the current 20 care plans were available to view and these confirmed that the home has implemented this system, with the majority of care plans signed off by service users and their representatives. In addition staff confirmed that service users have a monthly one to one session with their key worker during which issues regarding their daily routines, activities, etc can be discussed and may bring about changes. A summary sheet of this meeting is usually produced. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 10 Care plans are reviewed six monthly, although some local authority representatives are only able to participate on an annual basis. Two care plans in particular were reviewed in respect of a recent changing health need, and in another case a review of a behaviour management strategy, both plans viewed reflected the recent changes and additional associated risks have been reviewed in respect of one of these. Staff spoken with, indicated an understanding of the changed health needs of one of the service users and were observed providing appropriate monitoring and supervision of this person when they were moving from one activity to the next. The visit provided evidence that an outstanding recommendation for standard 8 regarding increased user involvement has been addressed. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 11 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) 16 The homes routines offer structure to those who need it but are sufficiently flexible to support the rights of users to move freely around the home, increase their independence and make choices in respect of their participation or not. EVIDENCE: Although not assessed fully on this visit, discussion with staff and service users indicated that improvements had been made to the older persons activity programme and a previous recommendation for standard 14 addressed. Discussion with users and staff clarified contact arrangements for service users and their families, and highlighted measures taken by the home to initiate, contact maintain and facilitate contact, a recommendation for standard 15 is therefore considered addressed. Staff were observed interacting in a friendly and age appropriate manner with service users, enabling and providing support in some in house activities, although the majority of users other day time activities are taken either at the day centre on site or at other external venues. Staff spoken with indicated Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 12 good insight and knowledge of individual users and their needs. Service users spoken with confirmed that they receive their mail and staff confirmed the arrangements for handling mail appropriately. The Home has in the past surveyed all the service users residing in the house as to whether they would like to have a lock and key to their bedrooms, at the time there was a limited take up. In view of recent opportunities for service users to participate in forums that will influence developments in the home, there is an increased sense of empowerment amongst them. As a consequence of this good work, the home should consider ways in which this could be developed further and it is recommended that as an initial step the home reviews the installation of locks on doors and makes this standard thus offering service users both the empowerment of controlling access to their rooms and actively offering them real choice to use the facility or not. Discussion with staff and observation of and discussion with some service users highlighted opportunities for service users to express preferences, to facilitate interests and hobbies, and to make choices about whether to participate in some activities or not, to move from one area to the next and to be on their own or quiet when they wish. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 13 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) 20 The Home has taken measures to ensure service users are protected by the Homes policies and procedures for the appropriate and safe handling of medication. EVIDENCE: The Home has a medication room that is kept securely locked, keys are retained by the senior on duty responsible for administration of medication. These are handed over at the end of shift. The medication room is appropriately laid out and was clean and tidy on the day of inspection. Requirements and recommendations issued by the CSCI pharmacy inspector earlier in the year in relation to practices within some of the smaller separately registered units on site related to some common medication practices in use across the site including Eastry House, The senior management team in the House have taken on board some of the requirements and recommendations issued elsewhere to improve there own practice. This inspection highlighted that the following requirements which would have applied generally to all units have been addressed at Eastry House, they are: Care plans viewed contained criteria for the issuing of as required medication, consents to medication administration by staff are now incorporated into care plans and reviewed accordingly. Hand transcriptions on MAR sheets are now signed dated and countersigned. Receipts of medications Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 14 were recorded on MAR sheets. A procedure for the disposal of medications has been agreed with the administering pharmacy. The House has also addressed good practice recommendations issued to the other units these include ensuring a list of specimen signatures of currently administering staff is available to view, and that the Home has a BNF for staff use, this was confirmed with staff, who have used it. Liquid medication should be dated on opening so that audits of usage can be undertaken and this is still to be implemented. The home is still to also include ‘as required’ medications in medication audits. The home is retaining medication storage temperatures and fridge temperatures when this is in use. MAR sheets viewed had photographs attached, which were copied onto the MDS system and user care plans, no omissions in recording were noted. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 15 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, 23 The home has a complaints procedure in place that is accessible to service users and other stakeholders. The Home has provided information and training to staff to ensure service users are not subjected to abuse, neglect or self harm. EVIDENCE: There are no outstanding or new complaints at this time. Written versions of the complaint procedure with widget symbols were displayed around the home for service users to access. Service users have an opportunity through monthly one to one sessions with their key workers if they wish to raise issues, service users spoken with were not entirely clear who they might go to with a problem if favoured staff were not on duty, the home may wish to consider whether user representatives who are currently involved in the service user committee could act as advocates for other less able service users or those who lack confidence in approaching staff with issues. The team leader confirmed that adult protection and whistle blowing had now been revisited with staff in supervision sessions but further adult protection training is planned for staff, the home were reminded of the need to ensure staff are aware of the Kent and Medway revised adult protection protocols and that any training with staff is undertaken with reference to these and this is a recommendation. Although at present none of the present service users of the house have behaviours which demand behaviour management programmes, some have minor behaviours where agreed strategies are in place and these were noted within care plans, the use of prescriptive language has been reviewed. Whilst all staff are trained by trainers accredited with BILD to deal with aggression from service users, none of those currently at the house Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 16 require any form of physical restraint and this is consequently not a feature of behaviour strategies currently in place. Eastry House H56-H05 S23387 Eastry House V242707 270905 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, 30 The home are addressing outstanding repairs and upgrades to the property to ensure that service users live in a safe comfortable environment. The Home has taken steps to ensure the home is maintained to a clean and hygienic standard and that service users are not placed at risk of infection. EVIDENCE: External works are currently ongoing to replace rendering to the outside of the building and reduce damp problems. Strip lighting in a user bedroom highlighted at previous inspections has now been replaced with domestic lighting, the radiator in that bedroom has also been guarded in view of risk to the individual service user. Provider visit reports highlighted some remedial works that were needed in some bedrooms and bathrooms and these have been addressed. First floor en-suite bathrooms, serving two user bedrooms have had replacement baths, and radiators installed. The Home has purchased carpet cleaning equipment and cleaning schedules are in place, these have made a significant difference to the control of odour and smells in one area of the home where issues of incontinence exist. The appearance of the lounge carpet which is required to be replaced by June 2006, has also greatly improved. The home was clean, tidy without noticeable Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 18 odours at the time of this visit and domestic staff were visible undertaking cleaning tasks throughout the home. The team leader advised that a previous recommendation that a wash hand basin be installed when the sluice area is redeveloped will be implemented when the laundry is updated, initial plans are already in place for the upgrading of laundry equipment. Eastry House H56-H05 S23387 Eastry House V242707 270905 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) 34 & 35 The Home have taken steps to improve efficiency in obtaining the required documentation to support staff recruitment consequently providing greater support and safety for service users. The Home have reviewed the staff induction training, but still need to evidence that the specialist needs of learning disabled users are addressed within staff training to ensure users are protected from abuse through ignorance, etc EVIDENCE: The Home has taken steps to address an outstanding requirement and ensure that staff files now contain information required by schedule 2 of the care homes Regulations and which support and underpin a thorough and robust recruitment system. Three new staff’ have been appointed since the last inspection, evidence of POVA first checks, and references were noted. It is suggested that in order that some consistency is applied to the content and quality of verbal references which often precede the provision of the written reference the home could use the same structure and content of the written reference request that will also go out to referees and this is a recommendation. The home has recently revised its induction programme for staff and is currently piloting this with its newest staff member, the manager was reminded of the need to ensure that the induction package is in keeping with Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 20 the proposed amendments to care staff induction which will apply from September 2005 and be mandatory from 2006. The home has not as yet used LDAF training, preferring to provide staff with specific training needed to meet the service users at Eastry House, LDAF training for new staff remains an ongoing recommendation in keeping with the expectations of the standsard, until the home are able to evidence that the induction programme adequately covers the skills and knowledge units provided in LDAF. The Home provides specific training courses on site for staff to gain more specialised knowledge where this may be relevant to the needs of users in the house e.g Dementia, autism. Staff induction records are now retained in staff files and addresses a previous recommendation. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 21 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) 39,42, The home has made some progress in improving opportunities for service users to express their views but will need to clearly evidence how this and feedback from other stakeholders influences change and development in the service. The Home ensures that appropriate systems, checks and training are in place to protect the health, safety and welfare of users. EVIDENCE: The home has made significant progress towards achieving this standard. Service users and staff spoken with confirmed that approximately one third of the user group have shown interest in being active members of a service user committee, this has already met and service users have given feedback in respect of environment and other issues, they are aware that some of these suggestions are being acted upon, and feel empowered to remain actively involved and act as representatives for others in the house, one service user spoken with who previously turned down the opportunity to get involved, is reconsidering in view of the positive experiences of those on the committee. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 22 Service users also have opportunities through one to one sessions with key workers and monthly resident meetings to express views. The Home also has a suggestion box and a newsletter. The home has introduced an audit system which will check a broad range of care and support tasks and functions, following discussion at inspection in respect of what is measured etc and how this is evidenced by the home, this is to be developed further. At present the home has no system in place for the collection and analysis of user or other stakeholder feedback, and is still to publish an annual report of the analysis of such feedback, and this remains an outstanding requirement. During this visit servicing certificates were reviewed for all electrical and gas services, and equipment used within the house for the care and support of service users, these were found to be updated, the manager advised that remedial actions in respect of an electrical inspection have now been addressed and a copy of the final certificate will be forwarded to CSCI as agreed at inspection. The fire book was checked and indicated checks and tests of equipment are happening in keeping with recommended frequencies, also fire training and staff drills are being undertaken regularly. The main corridor of the house contains three very large and heavy fire doors whose size and weight are in keeping with the period status of the property, however, their closure significantly inhibits the free movement of service users through the building, and accessibility for wheelchair users, they are therefore propped open. The manager advised that a recent visit from the fire brigade did not highlight this as a particular issue, and in view of the real difficulties their closure would cause to the independent movement of users in the house, a requirement has not been issued at this time, however, it is recommended that consultation with the fire officer for the area is undertaken as a matter of priority to discuss the appropriateness of door guards being installed, and whether these can be linked to the alarm system to ensure users safety in case of fire. Standard 43 was not assessed on this occasion, however, the inspector was able to establish through discussion with the provider and manager that whilst user development plans have been produced, a strategic plan which links to these is still to be completed and remains an outstanding recommendation. The inspector was advised that a previous recommendation that the Home clarify with their insurers that the recent change in Registration has not affected the insurance cover provided for each unit, has been addressed, although there was no written evidence to confirm this. Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 23 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 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x 3 x Standard No 31 32 33 34 35 36 Score x x x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eastry House Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 24 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. 2. Standard Regulation Requirement Timescale for action 30/6/06 30 16(j) (k) 3. 39 24 Main Lounge carpet to be replaced (previous timescale extended to be included on homes development plan still within extended timescale 30/6/06) Quality assurance policy and procedure to address all areas of quality assurance and quality monitoring (previous timescales nearly met) 31.12.05 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 16 Good Practice Recommendations Home to install locks with keys on all user bedrooms to afford opportunity for real choice on usage and empower users to take responsibility and control of their private space. Liquid medications to be dated upon opening and to be included in daily audits of administration. as required medication to be included in daily administration audits. Staff training in respect of Adult protection should be undertyaken with reference to Kent & Medway adult H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 25 2. 3. 20 23 Eastry House 4. 5. 6. 7. 8. 30 34 35 42 43 protection protocols. Wash basin for staff use to be installed when laundry and sluice area redeveloped format of verbal reference information to be formalised e.g use written reference template to ensure quality and consistency of information obtained. Staff new to learning disability to receive LDAF training Home to consult with fire officer in respect of door guards for fire doors in main corridor as a matter of some urgency Home to produce strategic development plan Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 26 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 Eastry House H56-H05 S23387 Eastry House V242707 270905 Stage 4.doc Version 1.40 Page 27 - 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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