Inspection on 26/06/06 for Ivy Cottage

This inspection was carried out on 26th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ivy Cottage 07/03/06

Ivy Cottage 10/10/05

Ivy Cottage 31/01/05

Ivy Cottage 20/07/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Ivy Cottage/Jasmine House/Rock Cottage Highlands Farm Woodchurch Ashford Kent TN26 3RJ Lead Inspector Mrs Sally Gill Unannounced Inspection 26th June 2006 09:05 Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.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 Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.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. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Cottage/Jasmine House/Rock Cottage Address Highlands Farm Woodchurch Ashford Kent TN26 3RJ 01233 861493 01233 860433 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) Canterbury Oast Trust Mrs Jennifer Ann Gorham Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Ivy, Jasmine & Rock Cottages are registered to provide accommodation for up to 11 adults with a learning disability and admits people with low dependency needs. Jasmine and Rock Cottages are used as semi-independent living units. Canterbury Oast Trust (COT) owns the home and the registered manager Jenny Gorham has day-to-day control. Ivy, Jasmine & Rock Cottages are three separate purpose built units with accommodation on one level. Jasmine is a unit accommodating 4 service users in self-contained apartments with their own bed sit, kitchen and shower/toilet. Rock accommodates 2 service users with their own bed-sits and they share a kitchen and bathroom. Ivy accommodates 5 service users in single rooms and has a shower/toilet, bath/toilet, toilet, laundry, kitchen and lounge/diner. Ivy and Jasmine would be suitable for those with mobility problems. Service users have access to a garden area with lawn and patio area with seating. The home is situated at Highlands Farm, which is a well-known tourist attraction in a rural area on the outskirts of the village of Woodchurch. A short drive will take you to the towns of Ashford or Tenterden, and approximately 3 miles away is Hamstreet train station. Within the village of Woodchurch there is the local GPs surgery, post office, church and two pubs. The home has transport, which can be used for service users if they wish and a local bus service passes the farm. The current fees are Ivy Cottage £798.69 & Jasmine & Rock Cottages £520.69 per week. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit took place on 26th June 2006 between 9.05am and 6pm, the registered manager, Jenny Gorham and four staff assisted with the process. Eleven people were living at the home with no vacancies. The inspector spoke to six service users (three only in passing) during the inspection and support and interactions were observed. The inspector accessed some communal areas of Ivy Cottage and one bedroom by invitation and the hallway and one apartment by invitation of Jasmine Cottage. The inspection process consisted of information collected before and during the visit to the home. Surveys were sent to service users, families, care managers and the Community Learning Disability Team (CLDT). Surveys were received from all service users (nine were completed with support from staff) the CLDT, care managers and four relatives. Feedback was generally positive and everyone is happy with the overall care and support received. Feedback from relatives expressed concern regarding the de-registration process of Rock & Jasmine and how this has been handled by management these concerns were also voiced by a professional. Various records were viewed during the inspection. What the service does well: Service users gave positive feedback both during the visit and through their surveys. Comments included “I like living here”, “I prefer it here to where I used to live because I can be more independent cooking my meals”, “I like Jenny (the registered manager)”. Apart form the de-registration process positive feedback was received from relatives including “x is so happy with COT and their standards of care are second to none”, “X is happy at Ivy Cottage and their current needs are well met”. The staff and manager are committed to meeting service users needs and provide an atmosphere, which is relaxed. Service users are protected by robust recruitment procedures; they have access to the local community and opportunities for a range of activities and holiday. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 6 The home is clean, safe, homely and well maintained. What has improved since the last inspection? What they could do better: The home must obtain a copy of the service users care manager’s assessment/care plan prior to admission to ensure all their needs and aspiration can be met. This should be retained on file to feed the care plan. An up to date care plan must be in place for new service users within a reasonable timescale following admission. All care plans should contain planning to develop skills and meet aspirations. Service users should be protected with up to date risk assessments in place for all risk management these should be reviewed regularly. Information in care plans and risk assessments should not conflict to ensure consistency for service users. Training should be linked to the Learning Disability Award Framework (LDAF) to ensure it is service specific. Service users and staff could be better safeguarded with improved detail in finance records where the home is responsible for handling service users monies. Minor improvements are required to the medication systems to ensure service users are fully protected including risk assessment for self-administration. Storage of complaints records should be improved. Where service users have requested they should have a key to their bedroom. Service users in relationships should have access to professional advice and guidance. Although the home is well managed and outcomes for the service users are on the whole good the home needs to continually look at ways where they can further improve the responsibilities and decision making and therefore the independence and skills of service users. There are some areas, which are Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 7 quite apparent. When decisions are taken the registered manager must ensure they are implemented. 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. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.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 Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.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 adequate. This judgement has been made using available evidence including a visit to this service. Formal assessments of prospective service users individual needs and aspirations are not used to inform decisions on whether the home can meet needs prior to admission. The homes own admission policy is not followed for internal transfers. EVIDENCE: One service user has transferred to this home since the last inspection from another home within COT. No care management assessment or care plan was obtained at the time of the transfer or is held on file. Obtaining and retaining a copy of the assessment/care plan has been discussed with the registered manager at previous inspections. The home is still completing their own pre– admission assessment of needs. The registered manager stated that she still hadn’t been able to assess all tasks on the assessment tool. The assessment tool is a pre-admission tool, which is used for new referrals, and this timescale is not acceptable. These assessments should be used prior to admission to ensure that the home is able to meet prospective service users needs and aspirations. The homes own admissions procedure states that reviews will take place after one and three months the file indicated that as yet no reviews Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 10 have been held. These timescales would indicate that any assessments would have been completed sooner than on this occasion. Old documents used by COT (IPP) have also been completed or nearly and the inspector cannot see the relevance of completing this ahead of the new format care plan as most of information is duplicated. The registered manager thought a copy of the SUG was displayed within the home although this could not be seen on the day of the inspection. All existing service users have received a copy when the document was completed but any new admissions should receive their copy of this document prior to moving in. The inspector accepts that the on this occasion the new service user probably did have the full information prior to moving in because they were already so familiar with the home. The service user confirmed that they were able to test-drive the home prior to admission. Contracts are in place with all service users although not all were signed by the home. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Not all service users assessed needs; personal goals and aspirations are reflected in their care plan. Service users are involved in decisions about their lives. Risk taking is supported to achieve independence but these are not always safeguarded with written assessments. EVIDENCE: Two care plans were viewed together with risk assessments. One care plan was reviewed as up to date and there was evidence of further handwritten entries however these were not dated or signed. Not all service users had evidence of goal planning to develop skills and meet aspirations within their care plans. Information in the care plan at times conflicted with information within the risk assessment because the risk assessment was not up to date. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 12 As previous mentioned the care plan of the new service user was not up to date. All documents within the care were still headed the previous home and there was only one risk assessment in place for this service users. The preferred name recorded in one care plan is not the name used by staff or preferred by the service user according to staff. Not all medication details were up to date in the care plan. The care plan, which was up to date, contained a good level of detail and should ensure consistency of support from staff. A key worker system is in place and service users are aware of their key worker and their roles. Service users spoken to felt they were able to make decisions around their own lives and about what happens in the home day to day although two service users surveys indicated that they were only sometimes able. Some service users manage their own finances and others are supported appropriately. Where service users are handling their own money this must be supported with a risk assessment. Service users meetings are held monthly with minutes where they are able to make decisions and give their views. One comment from a survey indicated that if staff are not comfortable with decisions/risks taken by service users this can result in service users feeling a negative attitude from staff which is not be appropriate. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 13 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): 11, 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 have opportunities for a wide range of activities and enjoy access to the local community. Some relationships would be better supported with professional guidance. Service users rights and responsibilities are respected although this and independence and skills could be enhanced through better planning. Service users are involved in planning, shopping and cooking a varied menu. EVIDENCE: Limited recorded goal planning was in place for some service users to maintain and develop skills and none for others. In some areas where service users have gained a level of independence further independence could also probably be gained (finances, medication, lunch). Through discussion it was highlighted that other skills such as shopping are being developed however this was not Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 14 recorded or monitored in records. It is important for staff to work with service users individually to find out their aspirations are as well so these can be achieved in addition to developing skills. Discussions confirmed opportunities to a range of activities and some service users have just returned from their annual holiday, which was obviously enjoyed. Service users have access to the local community and four service users have volunteer jobs one on site and others in the local community. Service users and staff talked of a variety of relationships with families and also friends. Relatives feel welcome in the home. Where service users are involved in a relationship specialist advice and guidance should be sought rather than staff trying to manage this themselves. Service users are involved in housekeeping tasks although at times this supported by a deep clean undertaken by staff. Some service users already have keys to their bedrooms however one-service user had requested a key back in May but as yet a key is still not available. The inspector was advised this is due to the keys not being available locally. Service users each take a turn to cook the evening meal, which are planned weekly with the lunch menus. Menus are varied and two service users are attending a slimming club with good results. Lunch was observed and further independence could easily be achieved here. Rather than staff doing the lunch, service users could get their own as they come in with a lunch menu that would allow for the time restraints. The registered manager stated that she agreed with this and it had been discussed with staff but they had continued to get the lunch. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 15 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 receive any personal support in the way they prefer and their health care needs are met. Improvements to the medication systems would fully protect service users and could aid more control of their own medication. EVIDENCE: Care plans detail how service users like to be supported and promote independence of personal hygiene. A key worker system is in place and service users are aware of these and their roles. Service users were dressed individually and talked about shopping for clothes recently and going to the hairdressers. Records showed that health care needs are met mainly within the community and service users have access to regular check ups. Currently there are no professionals involved in the care of service users. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 16 The medication recording system is not always clear but administration is recorded appropriately. The registered manager stated that she plans to change the recording system, which is complicated. Where there is selfadministration/part self-administration records should be improved. A risk assessment should be in place for all self-administration and the amount of medication issued to the service user must be recorded on the MAR chart so there is a clear audit and this can be monitored. This is also an area where probably further independence could be achieved with planning. Not all current medication details within the care plan are up to date. Internal and external medication should be stored separately. Records for logging medication into the home were muddled but complete. Staff have received medication training and when this is completed the registered manager undertakes a one off competency check. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 17 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. Service users feel their views are listened to and acted on although not all complaints paperwork was complete. Improved detail in service users finance records would safeguard both service users and staff. EVIDENCE: No new complaints have been received. One complaint has been resolved since last inspection although not all the paperwork was kept together or available for inspection. A complaints procedure is in place and was displayed within home. Service users feel their views are listened to and feel free to speak to staff regarding any issues. Where they have they said these have been resolved. Staff are trained in adult protection. A policy is in place to deal with abuse and staff were aware of where/how to report abuse both within COT and outside. Staff have enhanced disclosures in place. Service users monies are held securely which were checked against balances. The level of detail contained in records where the home is responsible for service users monies does not give a good audit trail of where/how monies are spent and for the protection of service users and staff these should be improved. There have been two adult protection alerts since the last inspection. One is now closed and was dealt with appropriately by the home. The other is a recent alert involving another service user from another COT home. The alert was raised by the CLDT and Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 18 the investigation is at this time ongoing. There is a recommendation to access professional guidance for service users who are in relationships. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. SU live in a homely environment, which is safe, clean and hygienic. EVIDENCE: The home was clean, tidy, safe and homely. Bedrooms were personalised and service users confirmed that they were happy with their bedrooms/apartments and that all equipment was in working order. The hallway in Jasmine has recently been redecorated and service users confirmed that they had chosen the wallpaper. Staff confirmed the maintenance department deal with any issues promptly. Service users were observed as having free access to all parts of the home. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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. A committed staff team support service users who are trained although training is not linked to LDAF. A robust recruitment process protects service users. EVIDENCE: The number of NVQ qualified staff is just below the target of 50 however when ongoing staff have completed the home will meet the target. Two staff files were checked and contained all relevant information to evidence a robust recruitment procedure is adopted. Where staff are started prior to a full CRB disclosure being in place the home must ensure that supervisory support is in place according to the amended regulations and records are maintained of this accordingly and available for inspection. A training matrix is maintained alongside a training file containing individual records and certificates. Induction for those files checked was to TOPSS specification however this is distance learning and there is no evidence of competency. The home is currently still working on old induction standards although COT plan to implement the new standards (Skills for Care) in Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 21 September with competency checks by the registered manager. Training is still not linked to LDAF. Staff are trained in core and limited specialist subjects although further training is planned challenging behaviour, sexuality for learning disability, autism and core subjects. See previous comment around staff not being comfortable with choices made by service users. Service users stated they are happy to approach staff with any concerns. There are comments from relatives around insufficient staffing levels although one said it had improved. Appraisals have been developed by COT and are about to be implemented by the registered manager. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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 views under pin the running of the home but their level of responsibility and input in the day-to-day running of the home could be improved. Service users benefit from a well run home where their health, safety and welfare is promoted and protected. EVIDENCE: Service users and staff confirmed that registered manager is supportive. Jenny has been the manager at the home for some considerable years and is qualified to NVQ level 4 in care and management and has good experience within learning disability services. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 23 The atmosphere in home was relaxed. In the inspectors view the home could improved the level in which service users take responsibilities and are involved in the day to day running of the home. The registered manager must ensure that when management decisions are made these are implemented by staff. Service users meetings provide good opportunities for them to voice their views. Quality assurance questionnaires were seen on file for service users and these are usually completed at or following the review. Where these were not positive the registered manager had responded in writing. Regulation 26 visits take place regularly where again service users are asked their views of the home and the commission receive a copy of the report. Health and safety checks are carries out regularly. Good maintenance of the home is maintained. The accident book was viewed and all reports are recorded appropriately. Staff are trained in core subjects. There are some concerns from families and professionals about the way management have handled the process and information consultation with regard the de-registration process being implemented. Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 24 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 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 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA 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 1 2 YA2 YA2 14(1) 14(1)(2) 3 YA20 13(2) The home must obtain a copy of the care management assessment prior to making a 30/06/06 decision about admission. Copies of care management assessments and/or care plan 07/08/06 must be held on service users files Operate a safe system for medication (separate internal/external storage, risk assessments for self administration, quantities of 26/07/06 medication given to service users are recorded, current medication is recorded in the care plan) 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 Care plans must be up to date, include service users aspirations and should be kept under review regularly Risk assessments must be in place for all risk management DS0000023447.V297295.R01.S.doc Version 5.2 Page 26 Ivy Cottage/Jasmine House/Rock Cottage 2 3 4 5 6 7 8 9 YA9 YA11 YA16 YA15 YA16 YA16 YA22 YA23 YA35 and reviewed regularly Improve planning to develop service users skills and independence to enhance opportunities for their decision making and involvement in the running of the home Access professional advice and guidance for service users involved in relationships Service users to have a key to their room where they have requested Service users preferred name to be recorded in their care plan Records of complaints to be stored complete and available for inspection Improve the level of detail in records of service users monies so there is a clear audit trail of how/where monies have been spent Training to be linked to LDAF Ivy Cottage/Jasmine House/Rock Cottage DS0000023447.V297295.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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