Inspection on 30/01/07 for Eastry Villas

This inspection was carried out on 30th 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 Villas 28/11/05

Eastry Villas 11/07/05

Eastry Villas 01/02/05

Eastry Villas 26/07/04

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 Villas High Street Eastry Sandwich Kent CT13 0HE Lead Inspector Julie Sumner Key Unannounced Inspection 30th January 2007 10:00 Eastry Villas DS0000048300.V304432.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 Villas DS0000048300.V304432.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 Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastry Villas Address High Street Eastry Sandwich Kent CT13 0HE 01304 611600 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) Family Care Homes Ltd Miss Rosemary Chapman Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Restricted to Ten (10) beds until completion work of additional two (2) bedrooms at Forge House site. 28th November 2005 Date of last inspection Brief Description of the Service: Eastry Villas is the collective name for three small units on or adjacent to the Eastry House grounds, owned by Family Cares Homes Ltd. The units are individually known as Mill House, Gore House and Forge house and are incorporated into one registration to be known jointly as Eastry Villas. The condition of registration for Forge House is in the process of being lifted as the final rooms have been completed. Forge house is a small semi detached period property adjacent to the car park of Eastry House, the property is registered to provide accommodation for up to 4 service users with learning disabilities who have achieved a degree of independence that enables them to undertake most of the daily household tasks with minimal staff support. Gore House is a detached house for three service users, (currently all female) who have some challenging and complex behaviours. Mill House is a detached unit for five service users (currently all male) with challenging and complex behaviour. The current fees for the service at the time of the visit range from £800.00 to £2200.00. 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 fchltd.headoffice@virgin.net All three units have sleep in staff. All bedrooms are single occupancy. It is an expectation that service users in the units will undertake some household tasks for themselves or with support. Limited car parking is available in the Eastry house car park or in the village. Service users of all three units have their own gardens but have access to the day centre on the Eastry site. Both Mill and Gore houses have downstairs bedrooms, but without additional alterations to both premises independent wheelchair users would find their movement and access to gardens etc restricted through environmental limitations. Eastry Villas DS0000048300.V304432.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 and a proportion of time was spent in each home. Timing was arranged around service users’ planned activities for the day and whether they were in or out. Altogether around 8 hours were spent within the homes. This included spending time with the registered manager in her office. There are some changes taking place both with the buildings and service users moving. One service user is about to move out of Forge House to a flat, one service user has moved out of Gore House leaving a vacancy and one service user who lives in Gore House is currently in hospital. The inspector spent time talking to service users and staff and viewing records and practices. 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 registered 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. At the time of the visit none had been returned. If insufficient time had been given for feedback prior to the inspection any comments received in future will be kept on the CSCI annual record and will be used to inform the next inspection. Service users gave some feedback during the inspection visit and some of the visiting professionals gave feedback for the service provided at Eastry House which can also relate to the Villas. There were no outstanding requirements from the previous inspection and some recommendations are ongoing. Three recommendations were made as a result of this inspection. What the service does well: Service users in Mill House and Forge House were really positive about their lifestyles and how they are being assisted to develop independence. They are furthering their education and skills by attending college, having work placements and having help to learn household skills. Service users also talked enthusiastically about their interests and recent events. The homes provide a comfortable, domestic setting. Service users enjoy living in the smaller units and the increased opportunities to access the community this brings. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 6 The homes 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 going to the gym, sports and learning about healthy food. 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. The registered manager, team leader and staff are well motivated and talked about plans for improved ways to support service users and make progress in the homes. What has improved since the last inspection? What they could do better: As stated earlier, there are various types of record and plan to support service users but the main service user plan is the standardized one that is produced by the company. The other plans have been designed in a more person centred way and with some developing, and involvement by each service user as far as possible; they could become the main plan. A recommendation has been made to review the care planning process and continue making the plans person centred in the way that the homes have already started. 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. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 7 There was a discussion with the team leader about the different types of first aid training and it was agreed that more staff should attend the 4 day training to make sure there is always someone on duty with this first aid qualification. This would also make sure that the home is complying with health and safety legislation. 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 team leader and key workers hold one-to-one meetings with service users to find out how they are and see if they are achieving what they want to. A new leaflet has been designed that contains a questionnaire to be sent out to get some feedback from relatives, visitors and other people 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 development plans for each of the homes in Eastry Villas and this needs to be finalised and follow on from the annual report. 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 Villas DS0000048300.V304432.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 Villas DS0000048300.V304432.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 homes although there have been some changes with one service user moving into Forge House from Gate House as a result of her wishes and a change in need. There is currently one vacancy in Gore House. Written assessments are clear. Eastry Villas DS0000048300.V304432.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 are involved in the compilation of the written plans to support their care. Service users know their changing needs will be recognised and 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: Service user plans were viewed and the different formats were discussed. The main plans are in the standardised company format and they contain some clear guidelines but on the whole they are not user friendly, are impersonal and there is little evidence to suggest that service users are involved in their compilation. However, the homes have produced their own folders that they call “grab files” containing relevant day-to-day information that staff can grab Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 11 quickly to get up to date information. These have been designed in a person centred way and are user friendly. There are also health action plans and these have been completed using service users’ answers and comments. This is potentially a much more effective service user plan and a recommendation has been made to review the format and develop these so that they become the main point of reference. Service users have an individual development plan that includes their aspirations and action plans for working towards it. The type of meetings and whether they have meetings to determine what people want varies from house to house. Service users living in Mill House and Gore House have one-to-one meetings with the team leader and there are key worker meetings also. It was decided that these were less stressful for service users and more productive. Service users in Forge House have planning meetings with their senior carer. Service users said that they felt they were able to decide what they would like to do with help from staff when they need it. 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 Villas DS0000048300.V304432.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. There is a good mixture of activities both leisure and educational that service users say they enjoy. 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: One service user has a work placement and discussed what he did. Service users attend college and describe the skills they are learning. Service users spoke about their interests and how they spend their time. Some of the activity plans were viewed and also discussed with the team leader. The educational and leisure activities reflected their interests. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 13 In conversation service users said they go out as much as they want to. Service users go out into the village either independently of with staff support depending on their risk assessment. Service users were observed going out into the village, going out attending planned activities and doing different activities in the home. 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, 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. The homes have transport so activities like horse and carriage riding, swimming and cinema are also part of the usual routine for some of the service users. Service users spoke about their families. They said they go home to visit and sometimes their family come to the house. The staff also said that relatives are able to be involved with the support if they wish. The homes 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 Eastry Villas and the other Family Care homes nearby. Service users spoke enthusiastically about the choices they have and how they are being supported to make decisions about day-to-day life. Routines are organised around work, college, personal care, appointments and planned occupational activities. Service users are supported with developing personal relationships. Staff have received training where needs have changed and a different level of support has been identified. 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. In Forge House service users are assisted to plan, prepare and cook their own meals. They have been given the opportunity to attend food hygiene and health and safety training. They are learning about eating a balanced diet. In Mill House and Gore House food is prepared by the staff on a turn taking basis and the service users assist depending on their skills and preferences. Samples of menus were viewed for each of the homes. Eastry Villas DS0000048300.V304432.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 encouraged to express how they want to be supported. 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. Health action plans have been designed and replaced the original medication “grab files” that had been designed by the team leader and staff in the homes. Health action plans viewed had been signed by the service user. They had been completed by Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 15 staff using the service user’s words and answers to the questions. They are working files with entries from visiting professionals including the G.P. physiotherapist, O.T. and chiropodist. Service users are encouraged to live an active and healthy lifestyle. One service user talked about learning about food that is good for you and how to cook it and going to the gym regularly to keep fit and lose weight. Service users are encouraged to take some responsibility for their own health. An occupational therapist was visiting a service user to make an assessment and give advice during the inspection visit. There was a discussion with the team leader about first aid training for staff. Currently the team leader and the registered manager have attended the four day first aid training and all other staff have attended the one day first aid course. There needs to be at least one member of staff on duty at all times who have the approved first aid training and there are current gaps in this provision. A recommendation has been made to increase the training provided to fulfil this and the team leader agreed that if all senior staff attended this training that would provide the necessary support. It was acknowledged that the staff did respond well to the accident in Gore House giving basic first aid and getting the ambulance without delay. Medication records, storage and guidelines were viewed and discussed with the senior member of staff in Mill House. A record is kept of stocks of medication that cannot be blister packed. Medication is checked when it has been dispensed on arrival into the home. A medication audit is carried out for administration, storage and staff competency and different members of staff are spot checked each time in each of the homes. This is carried out monthly and is overseen by the registered manager. Eastry Villas DS0000048300.V304432.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: Copies of the complaints procedure are available and are also designed using widget for service users with communication difficulties. Service users all said that if they had a problem they would talk to someone in the home. 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. All staff have also received CPI training. There is an emphasis on this in Mill House due to the potential frequency of displays of challenging behaviour. The company act as appointee for some of the service users. Some service users talked about money and how they are supported to manage it including learning about budgeting and housekeeping. All money spent with and on behalf of service users is signed out and accounted for with receipts and written records. A sample of records was viewed. Eastry Villas DS0000048300.V304432.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 environments are evolving with service users’ developing independence and in response to assessed needs. Service users are actively involved in choosing the furniture and décor in the home and their wishes are respected if they prefer a minimal decoration and ornaments. It is clean and well maintained. EVIDENCE: Tours of all three homes were carried out with the team leader. There is a planned cycle of redecoration and refurbishment, which was discussed with the team leader but redecoration is on hold due to the planned building work that is about to take place. Mill House and Gore House are currently in need of some repair and redecoration and this will be addressed when the building work is complete. The planned building work is included in the draft development plan for each of the homes. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 18 Forge house is very homely and the service users have been rearranging it to suit them and their lifestyle. There are major building plans about to commence in both Mill House and Gore House. This will include building another living room, extending the kitchen and creating a new laundry building. Bedrooms are all decorated to individual taste and with their involvement choosing colour schemes and décor. Staff have worked hard to make sure that service users are safe, that damage to property is limited by good management and that the environment is regularly reviewed. Service users dignity and privacy has been respected by providing alternatives to curtains when these have not been tolerated. The homes were clean. Staff have attended infection control training. Eastry Villas DS0000048300.V304432.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 NVQ training programme is underway. A good range of training is provided to meet individually assessed needs. There are robust recruitment processes in place protecting service users and good induction training. Service users benefit from an enthusiastic and supportive staff team. EVIDENCE: The staff structure was discussed. Samples of the duty rotas were viewed and discussed with the team leader. Some of the staff talked about their work and training. There is a programme of NVQ training. All senior staff have the opportunity to become NVQ assessors. The homes are working towards meeting the workforce target of 50 of the team to be trained. The current status is: Mill House – 6 staff in team – 1 has NVQ level 2 and 4 staff are studying 1 member of staff is booked to start in April. Gore House – 4 staff in team – 2 working on level 2 and 2 working on level 3. Forge House – 3 staff in team – 1 has NVQ 2 and is studying 3 an 2 are about to start level 2. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 20 Staff files were well organised and kept in the registered manager’s office securely. There are good employment records with documentation of relevant information regarding the decision to employ individuals. 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. The organisation of training was discussed with the team leader and training records were viewed. All staff in Mill House have received non-violent crisis intervention training as there is a focus on supporting adults whom may display challenging behaviour. Training is organised both internally and externally depending on what the subject is. Training courses provided are based on the assessed needs of individuals. All staff have attended courses on epilepsy and rectal diazepam, adult protection, understanding autism, and communication skills and some have also attended Makaton training amongst others. The registered manager and team leader have recently attended sexuality and relationships training which they said was really interesting and will assist them in supporting individual service users. The supervision chart was viewed. There is a structure of staff supervision with the team leader and senior staff carrying out supervisions. All staff had received supervision at the recommended intervals. Staff spoken to said that they found supervision useful and helpful. Eastry Villas DS0000048300.V304432.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, 39, 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 well managed homes. 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 management structure was discussed. A senior member of staff is based in each home. The team leader manages the three homes. The registered manager is based in the previous head office across the road and oversees all the homes. Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 22 The registered manager has been developing the quality assurance process for Eastry Villas. The team leader of the homes explained how information is gathered to inform management of how effective the service is and whether service users are getting what they want. There are several sources of information where feedback is gathered. Key workers spend time with service users as part of the care planning process and one-to-one meetings are held. 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 either by the team leader or the senior member of staff 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. The Eastry Matters news magazine is sent out to give information to interested and/or involved people and this encourages an open dialogue for feedback. There are development plans in rough for each of the homes and these were 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 homes have a fire risk assessment and keep a log of all checks and fire training which was kept up to date. The fire safety officer recently visited and gave a practical fire training session. Fire plans are displayed in each home. 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. The training matrix and a sample of certificates were viewed. Eastry Villas DS0000048300.V304432.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 3 STAFFING Standard No Score 31 x 32 2 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 2 x x 3 x Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 24 no 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. Make sure that there are sufficient staff on duty with approved first aid training in line with HSE ratios of staff to service users and having assessed the needs of the service. Staff would benefit from attending person centred planning training. Staff would benefit from attending person centred planning training. 2. YA19 YA42 3. YA35 Eastry Villas DS0000048300.V304432.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Kent and Medway Area 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 Villas DS0000048300.V304432.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!