Inspection on 29/01/07 for Eastry House

This inspection was carried out on 29th January 2007.

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 13/09/05

Eastry House 16/05/05

Eastry House 27/01/05

Eastry House 26/07/04

Eastry House 20/01/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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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 Julie Sumner Key Unannounced Inspection 29th January 2007 10:00 Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastry House Address High Street Eastry Sandwich Kent CT13 0HE 01304 619655 01304 621895 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) fchltd.headoffice@virgin.net Family Care Homes Limited Miss Rosemary Chapman Care Home 22 Category(ies) of Learning disability (22) registration, with number of places Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 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 30s upwards. The house is also home to a number of older people who have moved from long stay institutions. The current fees for the service at the time of the visit range from £325.00 to £1600.00. Information on the home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The provider web address is included in the previous page with other contact details. 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 few parking bays to the side of the property, however, parking is available in surrounding streets and a nearby car park. 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 DS0000023387.V307176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. Eastry House provides a long established, calm and friendly environment for service users. The inspector visited the home to talk to service users and staff and view records and practices. The time spent in the home overall was just around 7 hours at different times over two days. This included spending time with the registered manager in her office. Information was gathered for this inspection by a variety of means both prior to and during the visits to the home. The CSCI request information from the home routinely and the home manager provided all the information requested in the pre-inspection questionnaire prior to the inspection visit. Feedback questionnaires were sent out some time before the inspection visit. Feedback was received from service users who either wrote them independently or had some assistance from staff. Comments included: “the care is good and everybody is nice”, “I go out everyday” and “I like living here, I like my bedroom”. In answer to the question “what isn’t so good?” all answers were “nothing”. Feedback was also received from relatives, visiting professionals and a GP. All comments received about the home were positive for example a care manager stated, “I am impressed with the standard of care and attention to detail”. There were no outstanding requirements from the previous inspection and some recommendations are ongoing. Two recommendations were made as a result of this inspection What the service does well: The registered manager and deputy manager have a good vision and know what direction they want the care planning system to go into and how to encourage service users to participate in the plans and running of the home. The home communicate with relatives and visiting professionals very well. The Eastry Matters newsletter is quite widely distributed and well received and keeps everyone informed and welcomed. The standard of personal and health care is good. Service users are encouraged to lead a healthy lifestyle. Some service users spoke about how much they enjoy the slimming club that they are part of which is held in the home. There is a thorough recruitment process to make sure the company employs the right staff. There is a good system for training staff and providing them with the right skills to meet individual service users needs. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 6 The registered manager and deputy manager are well motivated and always considering new and better ways to support service users and make progress in the home. What has improved since the last inspection? What they could do better: The format of the service user plans needs to be re-designed. Where the deputy manager has been able to support a service user to participate in what the plan contains, so that it reflects what is important to that person, it has been much more effective. Each plan needs to be designed with each person so that it works for them, reflecting what and who are important, what they like and do well and what they want to achieve now and in the future. Any records that need to be kept for legal purposes could be kept in a different folder if they are not directly useful to each person. A recommendation has been made for this because it is a company format that needs to be revised. To help staff understand a new care planning process they would benefit from attending person centred planning training and a recommendation has been made for this. The registered manager has been working on a quality monitoring system and there are various ways the service is currently audited. The deputy manager has lots of different feedback from different meetings and discussions with people who use the service and those involved. A report needs to be written that brings together all this information so the home can see what they are doing well, what people like and where improvements could be made. This was discussed with the registered manager who agreed to write an annual report to use as the basis of the annual development plan and for this to be an ongoing process each year. The registered manager has roughly drafted a development plan for Eastry House and this needs to be finalised and follow on from the annual report. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 7 Recommendations have not been made for these last two points because the registered manager is already in the process of carrying them out. 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 DS0000023387.V307176.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their needs will be assessed by a competent person and that their care and support will be tailored to meet their needs. EVIDENCE: No new service users have moved into the home since the last inspection. There is one vacancy at present as a service user has recently passed away. Assessments are on going as part of the review of care plans and in response to changing needs. The registered manager also involves outside professionals and additional training is organised for staff if the need arises. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users would benefit from being more involved in the design and contents of the service user plan. Service users are supported to influence decisions about their own lives. Risks are identified, recorded and minimised ensuring that service users are protected and kept as safe as possible. EVIDENCE: A sample of care plans was viewed. There are various folders containing various reports, assessments and records including: health records, monitoring charts, daily records and guidelines for support. Reviews are held at least 6 monthly and more often if needs change. One person was having a review monthly because their needs were changing and they needed close monitoring to provide the appropriate support. Service user plans contain some clear guidelines but on the whole they are not user friendly, are impersonal and there is little evidence to suggest that Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 11 service users are involved in their compilation. However, one service user had written some of the guidelines and discussed and compiled some of it with the deputy manager. This was really good practice but due to the company policy it had then been typed into the standardised format so would not have been evident had this not been pointed out and original notes viewed. The format was discussed with the registered manager and the deputy manager who had already raised this issue with the company. The format needs changing to be more person centred and the manager said the company were considering ways to introduce this. There was evidence again that plans are reprinted at times and the information is not always accessible as a result. The manager said that this will be taken into account when the company review the format and the way the plans are presented. Also a copy is usually taken so that the information is accessible. Recommendations have been made to change the format of the service user plan so that it is person centred and for staff to go on person centred planning training to implement this effectively. The deputy manager and key workers get to know individuals and find out what is important to them. Different meetings are held with different themes and purposes but ultimately to give everyone a chance to air their views. For service users who cannot or choose not to participate in meetings they can have one-to-one discussions. One service user has expressed the need for more spiritual support and this has been provided for. Service users are being given more responsibility in how the home is run and two service users participated in the recruitment of the catering coordinator. A sample of risk assessments were viewed in the service user plans. There was a good range of risk assessments for all areas of each individual’s lifestyle. Guidelines for staff were clear and they were updated and signed when reviewed. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to choose from a good range of occupational activities to participate in both in the home and outside. Routines in the home are flexible and service users’ privacy is respected. Service users have the opportunity to maintain important personal and family relationships. The food in the home is of good quality and attractively presented. EVIDENCE: A variety of activities are available to service users. Due to the size of the home community activities are organised on a turn taking basis. Many service users are elderly and get tired easily. And everyone spoken to (including contents of written questionnaires received) said they go out as much as they want to. There are other activities arranged on site. In the home there is an art and crafts room. There is a day centre near the home in the grounds, Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 13 which is accessed by all the homes in the company. Service users can participate in drama, arts and crafts IT skills, literacy and numeracy and cooking. There is also a sensory room and service users can have massage and beauty therapy. Some of these activities are also available in the home. Service users go out into the village and the home has transport so activities like horse and carriage riding, swimming and cinema are also part of the usual routine for some of the service users. Relatives are able to be involved with the support if they wish. The home hold events that service users relatives are invited to. The news magazine Eastry Matters provides all relatives, visitors and interested people up to date with what is happening in both Eastry House and the other Family Care homes nearby. One relative commented, in a feedback card, how pleased she was that one service user was supported to visit her whilst she was unwell. Service users were in different parts of the home depending on what activities they were participating in. Some service users were spoken to in their bedroom and others in the communal parts of the home. Routines in the home are arranged around all the different activities and individual preference. One service user said: “I like living here and I get privacy. Its good to get privacy sometimes and its good to come downstairs sometimes.” The catering coordinator and kitchen assistant spoke about their role and a sample of the documentation was viewed and discussed. Copies of menus were included in the pre-inspection information given prior to the inspection. These are good, varied menus taking into account individual food preferences and diets and medical conditions. One service user has diabetes, which is diet and tablet controlled. The inspector had lunch with service users. Service users were given different choices. The kitchen is large and is not suitable for service users to participate in meal preparation. The kitchen was clean and is on the maintenance plan for refurbishment because it is old and the floor is damaged making it difficult to maintain the correct level of hygiene. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in the way they want. Service users’ health is monitored well and they are supported to maintain a healthy lifestyle. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: Guidelines for staff to support service users are written in the service user plan. Key workers get to know service users and enable service users to make their wishes known. All service users spoken to said that they were supported by staff in the way they want. All service users are registered with a GP. All have health care support included in the service user plan and there are lists of appointments to monitor health or as part of ongoing treatment and support of a health condition. Some service users have joined the slimming club and there are opportunities for service users to participate in activities involving exercise to keep active. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 15 Service users are encouraged to take some responsibility for their own health and there are discussions in the meetings, including the slimming club, about living a healthy lifestyle and eating healthily. A relative commented in written feedback that their relative living in Eastry House that “there has been a significant improvement in their condition”. The continence nurse has visited the home, made assessments and given advice when required. Medication records, storage and guidelines were viewed and discussed with the deputy manager. A medication audit is carried out by the deputy manager for administration, storage and staff competency and different members of staff are spot checked each time. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective complaints process. Service users are given the means to express their feelings. Service users are protected from harm by the policies and procedures in the home. Staff are knowledgeable about adult protection. EVIDENCE: A copy of the complaints procedure provided in widget is displayed in the home and accessible to service users. From feedback received, most relatives are aware of the complaints procedure All staff have attended adult protection training. New staff attend as part of their induction. Staff spoken to demonstrated an awareness of risks to individuals and what their role is. Care managers are informed of incidents and are involved in the reassessment of changes in need. CSCI are informed as appropriate of incidents under regulation 37. The financial procedures were discussed with the deputy manager. Some service users have a representative of the company as appointee. Some of the personal allowance is kept in the safe so that it is accessible for everyday things. Some records, receipts and money wallets were viewed. There is a signing out procedure for money from the safe, receipts are kept and all money spent on behalf of service users is recorded and accounted for. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and staff are constantly working to make this large, old building as homely as possible. There are some areas of the home that have been difficult to keep clean and some areas that do not smell fresh but the management and staff are aware of this and are taking appropriate measures to remedy. EVIDENCE: There is ongoing building development in the home and grounds to improve the environment. The current main entrance to the home is bare and cold but is included on the plans for improvement. Bedrooms are personalised and all service users spoken to said they liked their bedrooms. One service users said “ I like my pink bedroom”. Bathrooms look clinical and are in need of refurbishment. There is a flush floor shower in one of the bathrooms that has been refurbished more recently. One of the toilets was leaking and this is an ongoing problem but will be addressed as part of the refurbishment. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 18 The kitchen is on the maintenance plan for refurbishment to modernise it. The flooring is worn and has been patched where it has been damaged or around areas where there has been a change of appliance or storage unit, for example, around the new food chillers. There is good food storage and spacious cool storage which has been well organised. The maintenance plan for the building needs to be included in the development plan for the home with the areas identified as priority and a proposed timescale for completion. Cleaning schedules were viewed. The house-keeping staff keep the home clean. There are some mild odours present in parts of the home which is partly due to the very old building and being a care home for years. This has been brought up in inspections before and the staff team have been addressing this with different solutions for some time. A carpet cleaner has been purchased and new carpet or washable flooring have been laid as the need has arisen. There are intermittent dispelling air fresheners in some areas. One bedroom had an odour that was caused by incontinence following a gradual change in need and this was being addressed. Where there are incontinence issues appropriate washable flooring has been fitted. There are plans to build a new laundry building and this is on the company’s maintenance schedule that also needs to be included on the home’s individual development plan as discussed with the registered manager. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have a strong commitment to enabling service users to develop their skills, including social, emotional, communication, and independent living skills. There is a robust recruitment process and good induction process. Service users are involved in the recruitment process and their opinions valued and acted upon. Service users benefit from an enthusiastic and supportive staff team. A good range of training is provided to meet individually assessed needs and at least half of the team have NVQ level 2 or above. EVIDENCE: The staff structure was discussed. Samples of the duty rotas were viewed and discussed with the deputy manager. Some of the staff talked about their work and training. Staff are employed when the POVA check has been made and work under supervision until the CRB has been returned. New staff are allocated a mentor. Recruitment records were viewed and all were in place and complete. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 20 In a recent recruitment of the new catering manager, 2 service users were involved in the interview and making the decision from the applicants. A sample of staff files were viewed and discussed with the registered manager. All staff have received an induction. The newest member of staff has just completed her induction using the new revised format incorporating the general induction standards. She spoke positively about it. The recruitment process is satisfactory and effort is made to make sure that interaction with service users and their response is taken into account when deciding suitability. Service users benefit from an enthusiastic and supportive staff team. The NVQ training programme is underway. A good range of training is provided to meet individually assessed needs. The company provide training both internally and externally. The deputy manager has a training development plan. Training is ongoing and new course are organised as individual service users’ needs change or develop. There is a running list of staff attending mandatory training to make sure they are booked onto the next course when they need updating. Most recently staff have attended training in dementia as this need has been identified as service users are getting older. The deputy manager carries out staff supervision and they are routinely planned. Staff spoken to said they enjoyed working at Eastry House and feel well supported. The company provide an NVQ programme and staff spoke to had either achieved level 2 or were studying that or level 3. At least half the staff team have achieved NVQ level 2. Senior staff in the company, including the team leaders, are being given the opportunity to become NVQ assessors. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home. There is a good quality monitoring system in place. Feedback is sought in a variety of ways from service users depending on their understanding and communication skills. The home has a good record of meeting health and safety requirements. EVIDENCE: The registered manager is based in the previous head office across the road. The deputy manager takes more of a lead in the organisation of Eastry House overseen and supported by the registered manager. The registered manager has been developing the quality assurance process for Eastry House. The deputy manager explained how information is gathered to inform management of how effective the service is and whether service users Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 22 are getting what they want. There are several sources of information where feedback is gathered. Meetings are held with service users and minutes are taken. Key workers spend time with service users as part of the care planning process and one-to-one meetings are held with less vocal and less able service users who would not easily participate in group meetings. There are different meetings to discuss different areas of service users’ lifestyles and different service users participate. Staff meetings are held monthly. Monthly visits are conducted by representatives of the company to comply with regulation 26. The registered manager has set up a quality audit that includes health and safety, security, equipment and refurbishment of the home and is carried out 3 monthly. There are also medication audits and health and safety audits carried out by the deputy manager monthly. The registered manager explained that these generate action points and discussions and plans to implement improvement. At present there is no report that brings all this information together and this was discussed. The registered manager agreed to write an annual report to use as the basis of the annual development plan and for this to be an ongoing process each year. Eastry Matters news magazine sent out to give information to interested and/or involved people and this encourages an open dialogue for feedback. The development plan is in rough for Eastry House and this was viewed and discussed with the registered manager. The registered manager has produced a well designed leaflet for QA with a brief questionnaire to give people. The leaflet folds up into an envelope shape with address printed on front when folded ready to stick stamp on and send back. This has only just been designed so has not been sent out yet. The home has a fire risk assessment and keeps a log of all checks and fire training which was kept up to date. All equipment is regularly serviced. The home keeps certificates as a record. There is a rolling training programme to keep mandatory staff training up to date. Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations The service user plan format needs to be redesigned so that it is presented in a way that means more to service users. Where possible service users should be supported to be involved in its design and contents. Staff would benefit from attending person centred planning training. 2. YA35 Eastry House DS0000023387.V307176.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 DS0000023387.V307176.R01.S.doc Version 5.2 Page 26 - 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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