Inspection on 28/02/07 for Hevercourt

This inspection was carried out on 28th February 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

Hevercourt 26/03/08

Hevercourt 24/01/06

Hevercourt 21/09/05

Hevercourt 21/10/04

Hevercourt 11/05/04

Similar services:

Wingham Court

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hevercourt Goodwood Crescent Gravesend Kent DA12 5EY Lead Inspector Sue McGrath Key Unannounced Inspection 28th February 2007 12:30 X10015.doc Version 1.40 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 Hevercourt DS0000023955.V331353.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 Older People. 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. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hevercourt Address Goodwood Crescent Gravesend Kent DA12 5EY 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) 01474 363690 www.kcht.org Kent Community Housing Trust Mrs Christina Clark Care Home 46 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (21) of places Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Kent Community Housing Trust is a non-profit making Trust. Hevercourt is one of 22 residential care home’s owned and run by the Kent Community Housing Trust (KCHT) in the Kent and London areas. It holds Investors in People Award and has an ISO 9002 Quality Standard Accreditation. The general aim of KCHT, as expressed in its brochure, is to provide quality services which are flexible and affordable, meet the needs of individuals, preserve dignity and promote independence, and develop opportunities for fulfilment for people needing housing with care and for those who need care and support within their own homes. Hevercourt is a large detached premises surrounded by lawns and gardens and close to the A2 junction at Singlewell. It offers 37 single and 5 double bedrooms. There is a shaft lift serving all three floors with bedroom accommodation on the ground, first and second floors and other services (i.e. kitchen, lounges, smoking room, visitors room, hairdressing salon, activities room, medical room and staff room) on the ground floor. The Home is registered for 21 Older People and 25 Older People with a Mental Infirmity. Hevercourt is located on the outskirts of Gravesend and is within easy walking distance for most service users of shops and other public amenities. However, service users have good access to a KCHT minibus. There are extensive car parking facilities at Hevercourt and service users have access to two safe enclosed gardens at the rear. Fees range from £318.99 to £449.42 per week. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on 28th February and 1st March 2007 and was conducted by Sue McGrath, Regulation Inspector for The Commission for Social Care Inspection. The key inspections for care home services are part of the new methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through surveys sent to service users and relatives and information provided from professionals associated with the home, wherever possible. The actual date of the site visit is unannounced. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. Overall this was a positive inspection with generally good outcomes for service users. What the service does well: People who live in the home benefit from the support of a caring and committed staff team and an approachable manager who care for them with respect, good humour and dignity. Care plans include excellent information about the background and social history of service users to help staff to communicate with them and good information is available to help people who are considering moving to the home to enable them to make an informed decision. People who live in the home also benefit from the flexible routines within which they are able to exercise choice about their daily lives. A good range of indoor and outdoor activities are organised for residents. The pleasant and mainly well-decorated environment enhances the quality of life for service users, the premises have good facilities, are clean and easily accessible to visitors and the people who live there. The well trained staff understand the particular needs of people with dementia and the home has an experienced and well qualified management team. The staff group is dedicated and conscientious in their approach to work and will go the extra mile for the residents. This is evidenced by the level of fundraising undertaken by all staff. The atmosphere in the home is warm and comfortable. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with the information they need to make an informed choice about moving into the home. Residents benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. EVIDENCE: The Trust provides detailed information in the home’s Statement of Purpose, which helps the residents and their families make an informed choice about living in the home. The home’s service users guide was discussed with the Registered Manager and details were left regarding the recent changes that are Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 9 required regarding the information given on what is included in the fees. This will be revisited at the next inspection. All residents have a written contract which is signed by either the resident themselves or by their representative. Samples were viewed of recent admission procedures and discussion took place regarding who actually completes these assessments. The Registered Manager explained that they were always completed either herself or the Assistant Manager. The relevant forms hold good quality information about the prospective resident, which forms the initial care plan. Both staff have a good understanding of both dementia care and care for the elderly and are able to identify needs. The Registered Manager explained that all prospective residents and their families or representatives are welcomed and encouraged to visit the home prior to admission to identify if they like the home and what it has to offer. A minimum period of four weeks is offered before a final decision needs to be made over occupancy. This can be extended if necessary. Unplanned admissions are avoided whenever possible. A visiting family member confirmed this practise was followed when her relatives first arrived at Hevercourt. The home does not offer intermediate care. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated but the recording of these reviews must improve. Health needs are met and residents benefit from having full access to all professional health care services as required. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The Trust has introduced new care plans, which are comprehensive and detailed. Residents care needs are highlighted to enable staff to provide appropriate care. Residents benefit from the care provided by the dedicated and committed staff team, interaction observed is warm and friendly and care is provided in a way which respects and protects the dignity and privacy of Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 11 service users. Personal records include excellent information about the background and social history of people who live in the home to help staff to communicate with them. Night care plans give the necessary details to enable night care staff to fully care for residents. This area was highlighted in the last report but has been improved upon. A few minor adjustments to the care plans are recommended and these include a nutritional assessment (8.8), a list of monthly reviews with their outcomes (7.4) and space for either residents or their representative to sign to say they agree the plans(7.6). From the information contained in the plans it was evident that residents and families had been involved in drawing the plans up. It is also advised that with newer residents the care plans are carefully monitored to reflect the changes that take place during the first few weeks. It is noted that comprehensive daily notes confirm that good care is being offered. All residents are registered with a local G.P. and have full access to other professionals such as District Nurses, Opticians, Chiropodists and Dentists. Comments from a visiting District Nurse confirmed that a good working relationship is maintained with the home. The home’s system for the administration of medication meets with the requirements from The Royal Pharmaceutical Society of Great Britain. Medication is administered largely via a monitored dosage system. All staff that administers medication have completed an accredited course in the safe administration of medication. The home also has a policy in place that gives guidelines should any medication errors occur. People who live in the home can expect to be able to remain in the home until death so long as the home is able to continue to meet their needs, and they and their relatives benefit from the support of staff who have received training in bereavement and loss. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents social and recreational interest and needs are very well provided for with a wide range of activities organised. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents benefit from the meals and balanced diet offered by the home and those residents requiring specialist diets are well catered for. EVIDENCE: The home cares for people with varying degrees of dementia and lifestyles can be very challenging for some. With the levels of dementia within the home it is not always easy to ensure full choices are given at all times, however staff were seen to offer choices where possible and where not possible gave full support and consideration. Residents benefit from the flexible routines in the home, they are able to exercise choice in relation to routines of daily living. The home employs two activities co-ordinators who arrange activities for the people who live in the Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 13 home. Concerns were raised in the last report over whether all residents benefited from being offered activities. This had been addressed and staff now record all activities undertaken. This includes 1: 1 sessions for those residents who do not wish to participate in group activities. Residents enjoy many outing as the home has its own minibus. Residents confirm they enjoy these trips out and it helps to maintain contact with the outside community. The home has a high number of male residents and the manager is currently looking to introduce some male orientated activities. It is hoped to purchase a large shed where they can undertake activities such as carpentry, minor repairs and a potting shed, or it could become just a place to go and have a chat. Gardening is enjoyed by some residents and families are encouraged to become involved with the maintenance of individual flower beds with their loved ones. This has proved very popular with both families and residents. Residents also benefit from a wide range of activities in the home and these range from bingo sessions, quizzes, quiz nights, barbeques, strawberry teas, Easter parties, Christmas parties and Halloween parties. Families are always invited to these events. Raffles are arranged at these events to raise money to fund further activities. The staff recently completed a sponsored walk and raised sufficient monies to purchase a large screen and digital projector with woofers!! The residents are now able to enjoy large screen showings of DVD’s of their choice. This has proved very popular with the residents, especially the ice cream at the intervals. Several residents commented on how much they enjoyed the film shows. The home continues to endeavour to be proactive in the development of new ideas and activities and is piloting a scheme for the Trust that encourages some residents to maintain or rediscover previously held domestic skills. This also appears to be successful. Residents benefit from the flexible visiting policy that enables friends and relatives to visit at all reasonable times. Residents also enjoy some involvement with local community groups such as the local school, and a local minister conducts a religious service monthly for people who wish to take part. All visitors spoken with stated how welcomed the staff always made them feel. The majority of the comments from residents about the food are positive and all stated that choices are offered. The kitchen is clean and tidy and maintains all required documentation. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and service users and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: Residents who live in the home and their supporters are provided with a written complaints procedure and are free to offer comment or complaint. The home maintains summary of complaints as required and details are recorded in individual resident’s records. There have been some minor complaints this year but all have been dealt with appropriately. Residents are supported to vote through the arrangement of postal votes, which are arranged for those service users wishing to participate in the election process. The Trust has robust Adult Abuse and Adult Protection policies in place that protected from all forms of abuse. These include a whistle blowing policy to ensure the safety and protection of service users. Staff spoken with had a good understanding of Adult Abuse and were clear of their individual responsibilities. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents rooms are homely and comfortable not all service users benefit from living in rooms that meet the requirements for space. Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. The poor state of the windows needs addressing. EVIDENCE: Recent refurbishment work continues to improve life for residents but further work needs to be completed. The maintenance technician works hard to ensure bedrooms are regularly painted and that general maintenance is maintained. However the Trust needs to give consideration to the poor state of the window frames particularly in rooms 12, 27, 28 and 24. These are in Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 16 urgent need of repair or replacement. Also the window frame on the first floor landing, kitchen end, opposite the laundry yard is rotten and soft with parts missing. The majority of the windows need repainting inside and out. Some of the bedroom windows are leaky and very draughty. One has to have blankets draped around it to try to prevent the severe draughts in the winter. Some of the completed work includes decorating every bathroom and toilet. The dining room plus seven bedrooms have been decorated. The lounges and medical room were redecorated by outside contractors. The dining room floor has been replaced. A new front entrance has provided better security. Further consideration needs to be given to replacing the hall carpets, as these are over fifteen years old. Domestic staff work very hard to maintain the carpets appearance but they are showing signs of wear and tear and should be replaced as soon as possible. Residents who share rooms are mainly those who have dementia, therefore, it is impossible to make a judgement that it is their positive choice to share. Those who share are also adversely affected by the inadequate size of these rooms, which are too small to accommodate the furniture required within the standard. Some new bedroom furniture was seen and the manager stated she was hoping to purchase more this year. The residents do benefit from having very pleasant gardens, which are well maintained. The home was very clean and fresh on the day of the inspection and clearly domestic staff work hard to maintain this. Previous inspections have identified the need for specialist assessment of the premises by suitably qualified persons who would provide appropriate advice in relation to these issues. This work has now been completed and the majority of the recommendations have been implemented. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents who live in the home benefit from the support of carefully selected and well trained staff who understand their needs. EVIDENCE: Staffing numbers have been increased with extra staff being employed at most mealtimes. This has improved the service offered to residents. The home has sufficient staffing hours to meet the needs of the residents and staff spoken with agreed they do not feel under pressure and enjoy working at Hevercroft. The trust has comprehensive recruitment policies in place, which are closely adhered to. The newest staff file was examined and contained all of the required information to meet standard 29. The Registered Manager is fully committed to ensuring her staff are well trained and expects all staff to either have or be working towards their National Vocational Qualification in Care level two. Only three staff have yet to start their NVQ training and these are new staff that are due to start in the very near future. Other training also has a high priority and staff confirm they are encouraged to complete all training as required. The Registered Manager realises the value of having a well-trained staff group. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 18 The staff spoken with on the day were committed and friendly and stated they all enjoyed working at Hevercourt. Very good interaction was seen between staff and residents and all residents spoken with confirmed that the staff looked after them well and were very considerate to them. Comments made by residents were as follows: I have been here a long time and am very happy, the staff look after me well and I feel very safe. We have a pleasant lounge, which has recently been redecorated. I enjoy sitting in the lovely gardens in the summer. I enjoy my bath times, which are always very private There is always something going on, but I like the films shows best of all. We are taken out a lot and I think that is important. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, 33, 35, 36 and 37 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from having a competent manager who is well supported by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. Sound financial procedures protect residents and current arrangements to protect the health, safety and welfare of residents and staff are good. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager is very experienced and has managed the home since 1998. She has completed the Registered Managers Award and many other qualifications. Residents and their families benefit from the open door policy of the manager, which was demonstrated by the way residents felt free to wander in and out of the office for a chat during the inspection. There are clear lines of accountability within the home and the organisation with audit visits by the Registered Provider taking place every month. However some of the recent reports were not available for inspection. The manager stated that she was still waiting for the last report from the inspection in January. These are now completed by managers from other home’s. Responses from relatives received before the inspection and on the day of the inspection, indicated a general satisfaction with the overall management of the home. Staff also confirmed that they felt well supported by the management team and that their views were listened to. Regular resident meetings are held and again the outcomes from these meetings are taken in to consideration. The quality of life for people who live in the home and their supporters is monitored through annual quality questionnaires, which are sent to all relatives/representatives of the service users. However, the home does not have an in house continuous self-monitoring system in place, based on a systematic cycle of planning-action-review, which produces a report to the Commission in line with the regulations. The Trust does meet with relatives and residents to discus the outcome of the annual quality questionnaires at a yearly Forum and the manager has found that extra in house questionnaires as well, are not fully supported. The fact that residents and relatives can easily discuss issues with the manager at anytime reinforces the lack of interest in completing more questionnaires. The manager has tried to arrange further family meetings at various times of the day but the general response has been poor mainly due to the high level of satisfaction from the relatives. The Trust does supply the Commission with a report on the findings of the overall performance of the Trust. Where the money of individual residents is handled, the home maintains detailed and clear accounts on their behalf. A sound monitoring system is in place and the records are well maintained and accurate. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 21 Comments from staff confirmed they benefit from regular supervision and yearly appraisals. Detailed notes are kept with copies being given to supervisees. Staff who deliver supervision have received training. The safety of residents and staff is maintained through periodic routine tests and checks of fire precautions, records seen were in good order. There is a fire safety risk assessment and new procedures in place to ensure the home meets with the requirements of the recent changes to Fire Safety Legislation. Safety is further promoted through the regular maintenance of all equipment and installations; safety certificates were seen and were in good order. Safe working practices also protect residents from risk of harm through training staff in fire safety, moving and handling, first aid, basic food hygiene and health and safety. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 X X 2 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 3 3 Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 13 23(1)(2) (a and b) Timescale for action The windows throughout the new 30/09/07 need to be assessed and repaired or replaced as required. Requirement 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 3 4 5 Refer to Standard OP1 OP7 OP7 OP7 OP19 Good Practice Recommendations It is recommended that the service users guide be updated to include the revised guidance on service user fees. It is recommended that nutritional assessments be carried out as stated in the Nation Minimum Standards. It is recommended that service users of their representatives sign to say they agree the care plans. It is recommended that evidence be highlighted in the care plans of regular monthly reviews and their outcomes. It is recommended that consideration be given to replacing the carpets in the hallways. Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hevercourt DS0000023955.V331353.R01.S.doc Version 5.2 Page 25 - 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!