Inspection on 16/05/05 for Eastry House

This inspection was carried out on 16th May 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.

Other inspections for this house

Eastry House 08/01/09

Eastry House 29/01/07

Eastry House 13/09/05

Eastry House 27/01/05

Eastry House 26/07/04

Eastry House 20/01/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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 Unannounced 16/05/05 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. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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 Care Home 22 Category(ies) of LD 22 registration, with number of places Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25.01.2005 Brief Description of the Service: Eastry House is a period residence located in the high street of the village of Eastry, until recently the registration of the home also comprised three smaller houses, built on the site however, separate registrations have now been established to distinguish these from the main house. A further unit located on the boundary of the Main House is included in the registration for two of the other units. `Eastry House’, accommodates up to 22 adults with a broad range of learning disability and dependency aged from 20’s upwards, including a number of older people. Accommodation is provided in single and shared bedrooms, over two floors with several communal lounges, a dining area and activities room, and a number of bedrooms located on the ground floor. A programme of upgrading of Eastry house has been ongoing for several years which has now reached the stage of redecoration and refurbishment of bedrooms and bathrooms. 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 V225169 160505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken over a period of approximately 6 hours, during which a reduced number of key standards were assessed, as well as progress made by the home in addressing previous outstanding requirements and recommendations. During the visit a tour of the premises was undertaken, and discussions with five care staff and 1 domestic staff member, along with the manager took place. The visit provided an opportunity to meet and or observe the majority of house residents, with some participating in more in depth discussions with the inspector. Two relatives were spoken with during the visit. The programme of upgrading of the building is continuing with much needed replacement of some pipe work and installation of new baths in upstairs ensuites. A key pad lock to the main trade entrance to the house was found to be faulty and causing difficulties for staff opening the door, as this is a fire exit the Home have ordered a replacement lock to be fitted and this was discussed at inspection. The Home have taken on board some practice issues as a result of requirements around medication and will be implementing changes within required timescales. The Home was well staffed, there was a relaxed and homely atmosphere and staff spoke positively about their experiences of the home. Residents indicated opportunities for choice and decision making, and were generally satisfied with the amount of activities within the home, now that the day centre is offering additional things to do. What the service does well: What has improved since the last inspection? Staff turnover in the house has improved, staff spoken with spoke positively about team dynamics and support within the home from senior managers. The Home environment is improving all the time although in a period residence Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 6 there are limitations as to what can be achieved structurally. The Home management have responded to previous criticisms in respect of carpet cleaning within the house and this has improved significantly following the purchase of a carpet-cleaning machine. Menus for the day are recorded in the main dining area on a chalk board, a written copy of the weeks menu is also provided in the dining area, in addition to a picture of the main meal of the day, the home are continuing to develop opportunities for providing residents with more information about menus. Discussion with residents and house staff indicated that the provision of and range of activities has improved with the day centre now fully on line. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full 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 V225169 160505 Stage 4.doc Version 1.20 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 V225169 160505 Stage 4.doc Version 1.20 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 & 3 Key standard 2 could not be assessed as no new service user admissions have been made since the last inspection. The Home has a Statement of purpose and user guide but these need to be updated in consultation with service users. The Home is able to meet the needs of those service users currently in residence. EVIDENCE: The Home is still to address an outstanding recommendation to review the Statement of Purpose and user guide, and to ensure any omissions have been addressed including the inclusion of user views of the Home. Following the recent changes to the registration of the House and its units, separate Statements of Purpose and user guides are now required. The house will need will need to review and amend the Statement of Purpose and user guide to reflect the service offered at Eastry House only for prospective service users, and this should include environment standards met, details of accommodation etc. The Manager advised that a service user representative for the House will be undertaking a survey of users to obtain comments about the service and this will be incorporated into the User guide information, the manager has agreed to look at enabling service users to contribute to the user guide information by developing their perceptions of what the Home is like, and offers in the way of service and this is a recommendation. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 9 Observation of service users during the inspection, and observation of staff interactions with users and responses to needs highlighted no concerns that needs cannot currently be met, this was supported in discussion with service users, staff and two relatives, none of whom raised any issues relating to provision of appropriate care and support, a staff communication book viewed also indicated no particular concerns regarding the ability to support specific service users. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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,and 9 The Home has made little progress in making service users or their relatives aware of or involved in the care plan process. The Home provides Service users with opportunities to make decisions and take risks in their daily lives. Some progress has been made towards involving service users more in the running of the Home. EVIDENCE: Discussion with some of the more able service users indicated no knowledge or understanding of the care plan process or that they should have input into it, this was also reflected in a discussion with relatives undertaken during the inspection. Outstanding recommendations in respect of this have not been addressed. Whilst the home can cite instances of consultation and involvement of other stakeholders this is not generally the case and the Home has been slow to address previous criticisms of its failure to adequately consult, and to make internal decisions without the endorsement of all stakeholders. It is a requirement that the Home can evidence that it has been proactive in consulting and engaging with all stakeholders in respect of service user plans and gaining consent to plans. Discussion with staff indicated that changes to care plans were notified to staff through the handover process and in the communication book, staff indicated that access to care plans was not a routine feature of their work although this could happen on request, staff were Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 11 also aware that this system was changing and that they would have access to care plan information more easily, it is a requirement that this information is made accessible to all care staff. Discussion with service users and observation of them during the inspection, indicated that opportunities exist within established parameters for service users to make decisions in their daily lives and routines. Service users were observed participating in organised external activities and attendance at day centre, and some were observed opting out of this process. The Home have addressed an outstanding recommendation to extend opportunities for users to be involved more in the running of the Home, by establishing a regular newsletter, service user representation is involved in its development and content. A service user representative has been appointed and user views will be collected to incorporate in the user guide, Discussion with users and staff indicated that where possible and able to users are encouraged to maintain and develop independence, which will involve taking risks e.g. going out unaccompanied, learning domestic skills e.g. washing up, undertaking personal care routines, taking on board helper jobs around the home, going on holiday, etc, in response to a previous recommendation the home is now recording reviews of risk assessment on a daily basis for those adults with challenging behaviours who are accessing the community. Although standard 10 was not assessed on this occasion the Home has addressed an outstanding recommendation in respect of the development of a confidentiality statement, and this is now incorporated into all review and client report information, disseminated to other stakeholders. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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) 12, 13, 15, 17 The Home has made good progress in the development of a varied activities programme, has continued to support and maintain a community presence for service users. Could be more proactive in maintaining or establishing links with families and relatives. Has made progress in providing accessible information about meals to service users. EVIDENCE: With the recruitment of an additional day care worker the activities programme within the Home and day centre provide for an improved and varied activities programme this was supported in discussions with service users and staff, who perceived a significant improvement in the amount of activities, with users expressing satisfaction at having an active programme. Service users confirmed trips out for shopping, trips to places of interest, other day care settings, planned holidays etc, The support for service users to maintain a presence in the community through church attendance and visiting the local pub and shops was also confirmed in discussions with users and staff. An escorted activities book indicated access to external outings, college, day centres, shopping, pub, and church trips for a number of service users not all of whom are the most able. The activities book also indicated that several Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 13 residents participated in the recent general election process. It was noticeable that although some work has been undertaken to involve older residents in the activities programme, this has been only marginally successful with some residents either not being enabled to facilitate to attend or being allowed to opt out of activities, and further thought needs to be given to provision of stimulating activities for older and more physically disabled residents and this is a recommendation. Relatives spoken with were positive about their relationship with the Home and staff, they were made to feel welcome and felt well informed by the home staff. The manager advised that the majority of service users do not have families actively involved with them, and contact is not maintained. This is an area where the home could be more proactive in trying to establish links or maintaining contact on behalf of the resident and this is a recommendation. Since the last inspection the Home are ensuring that the weekly menu is made available in the dining area, the lunchtime menu is recorded on a chalk board and a picture of the main meal is openly displayed. One service user spoken with indicated that they sometimes prefer to have a salad and this is made available for them. Most residents spoken with who were able to express an opinion were satisfied with the meals they received. Portions viewed were substantial, freshly cooked and well presented. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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, 20 The Home provides individualised personal support to service users where required and ensures their physical health needs are addressed. EVIDENCE: Discussion with service users during the visit indicated a wide range of abilities and needs with some people able to undertake quite substantial amounts of their own personal care, with other people requiring almost total support. Those users able to express a view were satisfied with their own personal arrangements. All residents observed during the visit were well groomed and presented in clean and weather appropriate clothing. Staff’ knowledge of individual user preferences and routines was good, they indicated that they got to know about individual preferences in respect of routines through their induction and through liaison with other staff and the service user, changes to routines or care arrangements were highlighted at handovers and in the communication book. This was evidenced in documentation viewed. Escorted activity documentation indicated visits for dental and other routine health appointments, one service user confirmed recent attendance at dentist with some follow up treatment, another resident experiencing a health issue had requested a doctor appointment and this had been organised for the next day. Handover sheets indicated staff flagging up health issues to each shift to ensure these are addressed. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 15 Medication was not assessed fully on this occasion owing to outstanding requirements as the result of a CSCI pharmacy inspection. A compliance visit will be undertaken once timescales have been passed. A medication round was observed, when both hygiene and administration was satisfactorily addressed by administering staff, all of whom have been trained. Staff were observed to maintain the security of the medication trolley at all times, MAR sheets were signed only after medications were observed to have been taken, water was provided for service users taking medication. Security of medication keys is established within staff handover protocols. MAR sheets viewed were satisfactorily completed and contained photos of service users, administering staff are aware of changes to be implemented as a result of the pharmacy requirements and that the Home is changing to an MDS system of administration. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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) 23 The Home has an adult protection procedure and a whistle blowing policy, staff need to be familiarised with them, EVIDENCE: Discussion with two staff indicated a good understanding of whistle-blowing and adult protection. Staff spoken with had experience of the whistle-blowing process but in one case could not recall what the process was called and in both cases neither could recall seeing the Homes policy, and could not be sure therefore that they would comply with it, although both indicated referral to appropriate agencies or lines of management accountability. Both staff spoken with were clear about actions to be taken in the event of an adult protection disclosure etc but again could not be sure this was compliant with Home policy and could not recall seeing it, although were sure they probably had. It is a recommendation that senior staff revisit adult protection and whistle-blowing policies within supervision. The inspector viewed individualised behaviour guidelines for two service users with challenging behaviour, observation of staff interacting with one user indicated that although boundaries were clearly in place and staff were managing responses, those responses specifically established in the guideline were not being adhered to and the home should review whether a prescriptive adherence to exact wording is required or whether staff can be more flexible as long as boundaries are maintained, and this is a recommendation. All behaviour management guidelines must be reviewed for effectiveness and establishment of any restrictions must not be undertaken without the involvement and endorsement of all stakeholders in a multi disciplinary forum. Although staff spoken with have been trained in break away techniques, the focus within the house is for distraction and diversion techniques to be used Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 17 with restraint as a last resort, physical interventions of any kind must be clearly detailed within individualised guidelines if they are to be used however, infrequently and their use strictly monitored, and this is a recommendation. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 The home has made some progress in improving the environment for service users and the general standard of cleanliness throughout. EVIDENCE: A programme of maintenance and upgrading is now underway in the home, with some bedrooms and shared bathrooms being upgraded to address outstanding recommendations. All bedrooms viewed at inspection were pleasantly decorated and furnished, reflecting the individual interests and tastes of the residents. A staff member spoken with confirmed involvement in painting a residents bedroom with the resident, and that the resident had selected the colour scheme for the room. A recommendation that strip lighting be replaced in two ground floor bedrooms has been partially addressed with one room still waiting for Strip lighting to be replaced and a radiator to be covered. Single toilets on the first floor without washbasins have had alcohol gel dispensers installed as an interim measure. The Home management have discouraged the practice of piles of clean towels being left in bathrooms and toilets and these were not in evidence on this inspection. The Home has invested in the purchase of an industrial carpet cleaner and this has made a significant difference to the presence of odour in some areas of the Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 19 home which was unpleasant for service users whose bedrooms were located in those areas, or who were subjected to unpleasant odour in communal dining/lounge areas, the general appearance of carpets has improved, including the lounge carpet, as a consequence of this there is no longer a pressing requirement for this to be replaced and this can be addressed within the longer term development plans for the Home within the next year. Domestic housekeeping staff spoken with confirmed the presence of cleaning schedules and carpet cleaning schedules were viewed for the home, staff spoke positively about the effect of the new carpet cleaning system, and felt that this had made an improvement to the cleanliness of the Home. Staff spoken with discussed the management of soiled laundry and are adhering to infection control procedures, gloves and aprons were in evidence for staff undertaking personal care and supplies noted in bathrooms for staff use. The manager advised that there are still plans to redevelop the laundry and sluice area at which time an outstanding recommendation for the inclusion of a staff wash basin will be addressed, this therefore remains a recommendation. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36 The Home is adequately staffed to meet the needs of the current number and dependency of service users, some progress has been made to ensure a robust recruitment procedure is in place. Staff are well supported and supervised appropriately. EVIDENCE: A staff rota indicated satisfactory staffing levels for the numbers and dependency of service staff spoken with indicated that only one resident required two staff to put them to bed other residents being moved by use of hoists. Staff indicated a view that staffing was sufficient at present. Observations made during the inspection indicated staffing to be sufficiently flexible to enable escorted outings to take place, with adequate staff left to spend time with specific residents doing hand massage, talking and conversing with others, encouraging and prompting others to undertake activities etc. The Home has made some progress in addressing an outstanding requirement in respect of the recruitment process by ensuring a POVA first check is carried out on all staff prior to commencing employment, however, staff files viewed indicated an over reliance on verbal references and an absence of some written references, this remains an outstanding requirement. Staff spoke positively about the current staff team in the house, they perceived staff turnover to be less than previous occasions, staff indicated they felt well supported and Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 21 listened to by the current management team, and were made aware of developments, and that formal supervision of staff is happening regularly. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 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) 38, 39, 43 The home have made progress in developing good team dynamics and an inclusive management approach. Systems for undertaking quality checks exist but the Home has made limited progress in developing a comprehensive Quality assurance policy or producing development plans to support much of the improvement and development works ongoing and planned. EVIDENCE: Staff were very positive about the management approach of their immediate line manager who they felt was supportive, and had facilitated good team dynamics. They felt listened too and able to make contributions and ideas for development of the service. Relatives also confirmed they felt the management approach was inclusive, they were also made to feel welcome and were kept informed, they confirmed receipt of the Homes newsletter which they found informative. A number of quality assurance checks are in place in the Home but these are still to be incorporated into a quality assurance policy and procedure and this remains an outstanding requirement although some progress has been made towards achieving this standard. Staff and resident meetings are being held and the home has appointed a user representative. Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 23 The providers are closely involved in the oversight of the Home and systems are in place for the monitoring of budgets. However, despite intense activity and investment from the providers around training, environment improvements, management structure changes etc, the Home is still to produce development plans and this remains an outstanding recommendation. A current insurance certificate was displayed, owing to recent changes within the registration the Home will need to explore how the insurance arrangements for the sight will need to be provided and it is a recommendation that this is clarified with the insurers. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 3 x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 Eastry House Score 2 3 Standard No 24 25 26 27 28 29 Score 3 x x x x x Version 1.20 Page 24 H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc 8 9 10 LIFESTYLES 3 3 x Score 30 STAFFING 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x x 3 Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 25 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 1 Regulation 4&5 Requirement In view of recent changes to the registration of Eastry House and other units on the site the SOP and SU guide are to be reviewed in consultation with service users. a)All Service users, and /or relatives/representatives are to have access to care plans, and sign agreement to them, b)care plans must be accessible to service users/ relatives/representatives and staff at all times. Main lounge carpet to be replaced (previous timescale of 30.9.04 extended to be included on Home development plan) Pova checks and 2 satisfactory references to be in place prior to staff commencing work (previous timescale of 28.1.05 partially met). Quality assurance policy and procedure to address all areas of current quality assurance and quality monitoring to be developed (previous timescales only partially met) Timescale for action 30.7.05 2. 6 15 30.8.05 3. 30 16 (j)(k) 30.6.06 4. 34 19(1) & schedule 2 24 30.6.05 5. 39 30.7.05 Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 1 6 Good Practice Recommendations user involved in development of user guide, detail of description of service and whats offered, also incorporate user views of service service users to be involved in development of risk assessment and sign agreement to where able to. User files to comply with schedule 3 of Care Home regulations in respect of photographs consideration to be given as to how user involvement can be extended including their involvement in the development and review of the Statement of purpose and user guide Home to review activities programme for older service users Home to be more proactive in making and maintaining contacts with families on behalf of service users and in the spirit of consultation a)Managers to revisit Homes adult protection and whistle blowing policies with care staff in supervision b) User behaviour guidelines to be reviewed and agreed within multi disciplinary forum for :-effectiveness, restrictions and reward systems to be clearly stated, and agreed to, physical interventions irrespective of frequency of use must be clearly stated in guidelines and their use monitored, use of prescriptive language to be reviewed for relevance. strip lighting to be replaced in one ground floor bedroom and radiator covered installation of washbasin for staff use when the redevelopment of the sluice area and laudry commences staff induction records to be retained on staff files for a minimum of six months and available for inspection a)Home to provide written development plans b) Home to clarify with insurers whether current insurance certificates take account of recent registration changes 3. 8 4. 5. 6. 14 15 23 7. 8. 9. 10. 24 30 35 43 Eastry House H56-H05 S23387 Eastry House V225169 160505 Stage 4.doc Version 1.20 Page 27 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. 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