Inspection on 15/06/06 for Mariners Folly

This inspection was carried out on 15th 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mariners Folly 03/07/07

Mariners Folly 29/12/06

Mariners Folly 25/10/05

Mariners Folly 18/05/05

Mariners Folly 12/10/04

Mariners Folly 14/04/04

Similar services:

Lyncol House

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Mariners Folly 194 Parrock Street Gravesend Kent DA12 1EW Lead Inspector Robert Pettiford Key Unannounced Inspection 15th June 2006 10:00 Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 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 Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 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. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mariners Folly Address 194 Parrock Street Gravesend Kent DA12 1EW 01474 361935 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) Dharshivi Limited Mrs Eleanor Kathrine McGinley Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: The home provides care and accommodation for up to 13 people with learning disabilities. Service users have single bedrooms, on 3 floors (not served by a lift). Twenty-four hour care is provided (with an awake and an asleep member of staff on duty at night). The home is in the centre of town with good access to local amenities. There is a small patio area at the rear and a large car park. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started on 15th June 2006 at 10:00am and was concluded on the 16th June 2006. The Inspector agreed and explained the inspection process with the owner and staff present during the inspection. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. The focus of the inspection was to assess Mariners Folly in accordance to the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The home does not have a registered manager in post at present. The management of the home is currently being overseen by the owner. A Manager has been recruited and is scheduled to start shortly following the resignation of the previous manager. Time was also spent by the inspector observing and talking to service users and staff discussing the standard of care within the home. The range of fee’s charged for services provided range from £485 to £520 per person. What the service does well: What has improved since the last inspection? Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 6 Improvement has been noted with regard to offering service users opportunities for personal development and to learn new skills and feel part of the wider community as they wish. The staff have been instrumental in supporting service users to promote their independent living skills. 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. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome group is adequate Prospective service users have on the whole all the information they need to make an informed choice about whether they wish to live at the home. Service users can not be confident that their needs will be suitably assessed prior to moving into the home. EVIDENCE: A Statement of Purpose at Mariners Folly was found to include most of all the information as required of Schedule 1 of the Care Home Regulations 2001 to enable prospective service users to make an informed choice about accepting a place at the home. The owner was requested to review the Statement of Purpose to ensure it meets with the standards and ensure that the service users guide is in a format or formats that is appropriate for all the service users living within the home. The owner at time of inspection was unable to evidence that the home had any formal assessment process. Due to the departure of the manager the owner stated that information was not available to evidence any compliance with the standards. The owner was requested to review all the homes procedures with regard to assessment to ensure that it had a system in place that meet with the standards. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 9 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 group is adequate Service users benefit from having individual plans that identify their physical and medical needs, but not enough detail was given to social and personal goals. Service users can not always feel confident that they are fully supported to take risks within a risk assessed framework. The service users can be confident that their rights to make decisions about their lives is respected and they are consulted on, participate in, all aspects of life within the home as they wish. EVIDENCE: The inspector viewed and discussed with the owner and several members of staff the care records relating to several service users at Mariners Folly. In the care plans viewed there were some guidelines in respect to support needed. From evidence seen at time of inspection formal reviews involving significant professionals and relatives where possible were not regularly undertaken. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 10 No evidence was available that service users were involved in drawing up personal care plans in the documentation seen or that they are consulted in reviewing and amending such care plans. The support evidenced within the care plan with regard to challenging behaviour did not show enough detail with regard to triggers that would inform staff to enable them to follow an agreed behavioural management plan. This is required in order to have a consistent approach by all staff and support the service user in the best way possible. Care plans viewed were seen to be disorganised and incomplete without giving clear guidance to staff Risk assessments were reviewed within the home and discussed with the manager. Assessments seen had limited detail on how to support service users to minimise risks for personal safety and risk assessment seen had not been updated and reviewed. It is evident through talking to members of staff at Mariners Folly that the emotional health of the service users is of a high priority to the home and that staff are pro-active in maintaining and supporting service users with their emotional needs in order to maintain their quality of life. This was not fully evidenced however within the care planning process as previously identified. The inspector first visited the home at 10:00AM. During the inspection the inspector noted that service users were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the service users interacting with staff. The inspector found that the home has a genuine commitment in evolving the service user in the day to day running of the home. Staff were responsive and receptive to the service user’s input. Examples of such included choosing activities and planning of the day ahead. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 11 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): 11,12,13,14,15,16,17 Quality in this outcome group is excellent Service users can be confident that they are offered opportunities for personal development and to learn new skills and feel part of the wider community as they wish. Service users engage in activities which are appropriate to their needs. Service users are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The service users benefit from the appetising meals and balanced diet offered at the home and enjoy preparing their own meals. EVIDENCE: Service users are able to enjoy a full and stimulating life style with a variety of options to choose from. The home has sought the views of residents and considered their varied interests and abilities when planning the routines of daily living and arranging activities. Routines are very flexible and residents Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 12 can make choices in major areas of their life. The routines, activities and plans are resident focussed, regularly reviewed, and can be quickly changed to meet individual residents needs. Service users are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house. Thus providing them with opportunities to maintain and develop, communication and independent living skills. Service users enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home in accordance with their needs and wishes. It was confirmed that service users are enabled to maintain contact with relatives and friends where they wished to do so. Service users were consulted with regard to whom they saw and when and were under no compulsion to accept visitors should they not wish to do so. The system in place and the practice and attitude of the staff team give service users the opportunity and support to remain independent. They are encouraged to be responsible for their own money for as long as they wish, and are able to maintain their independence, for example, collecting their own money, paying for personal shopping and managing their own bank accounts. Staff give help when it is needed and have contacted advocacy groups and encouraged their involvement with individuals in the home. Service users from records viewed it was evident that service users were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the service users’ activities and schedules. Service users are able to choose where to eat, and also have facility to make drinks, meals and snacks for themselves and others. Service users on evidence seen have had been involved in planning and choosing menus. Staff talk to and interact with service users, not exclusively with each other. Service users choose when to be alone or in company, and when not to join an activity. Service users have unrestricted access to the home and grounds. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 13 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 group is adequate Service users feel supported by the level of help given and that their healthcare needs are addressed. Service users can not feel confident that their welfare is protected from harm by the home’s policy and procedures with regard to the administration and dispensing of medication. EVIDENCE: Times of getting up / going to bed, having baths, eating meals and other activities are flexible to allow for different service users daily routines. All service users were able to make their own choice’s with regards to what they wished to wear, and this was evident by their individual appearance. The inspector observed excellent interaction between staff and service users. The documentation seen confirmed that all service users have a GP and visits from other health professionals are arranged and enabled. The health care issues of the residents were seen recorded in the daily record. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 14 The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication within Mariners Folly. The owner confirmed that all staff who dispense medication have received the appropriate training. The inspection of the home’s system for storage and the administration of medication brought to light several concerns. The inspector requested that the need to write up the MAR sheet is reduced to an absolute minimum. If it was necessary in limited circumstances (following a private consultation between the service user and the Doctor) to add items to the sheet, that it is checked and verified by two members of staff. It is also requested that a copy of the prescription be kept to verify correct drug, dosage, and time of administration, to ensure that it had been recorded properly. The MAR sheets (drug record sheets) were not being completed properly. Doses were missed and the MAR sheet was unable to indicate a reason for missing the dose, or the member of staff involved. The box was left blank. Had the dose been forgotten or refused? The medication file / Mar sheets did not have a signature list to evidence who gave the medication signed for on the Mar sheet. Eye drops were found that should have been discarded within 4 weeks of opening and old medication that should have been returned to the chemist was also found. The home should ensure that the temperature of the medication is monitored on a daily basis to ensure that it is stored within the temperature range as stated in the information leaflet supplied with the medication Prn or as required medication protocols were not written up correctly. The home could not demonstrate that as required medication is given following an agreed protocol or reference to the service users care plan. This should state when and how and under what circumstances any Prn medication is given and anti – psychotic medication needs to refer to an agreed behavioural management guidance. The owner agreed to review these issues and confirm in writing to the Commission that the medication policy follows the Royal Pharmaceutical Society guidelines (June 2003) amended. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 15 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 group is poor. Service users rights are not fully protected with regard to making complaints. Service users are at risk of possible abuse due to lack of polices and procedures and lack of understanding of adult protection procedures. EVIDENCE: The complaints procedure seen within the home at time of inspection did not meet met with the National Minimum Standards. The complaints procedure did not contain all of the information as required of the standards with regard to timescales for responding to a complaint and was found not to be in a format that was on the whole appropriate for all service users living within the home. The owner was unable to evidence at time of inspection that the home had up to date policies and procedures for the Protection of Service Users and staff “Whistle blowing” procedures. These should include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. The manager stated that staff had received the training required to protect service users from abuse although this could not be fully evidence due to lack of comprehensive training records. The owner did not have a copy of the Kent and Medway Adult Protection Procedures within the home and was unaware of its existence. The owner was requested to ensure that the home takes steps to ensure that it meets with the standards and detail in the homes action plan on how compliance will be meet. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 16 Not all staff have a CRB (Criminal Records Bureau) or POVA (Protection of Vulnerable Adults) checks which is a legal requirement. The owner was requested to address this a priority. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 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): 24,25,26,27,28,30 Quality in this outcome group is good. Service users benefit from living in a home which is suitable for their needs, clean and comfortable. EVIDENCE: The Inspector undertook a tour of the home, with their permission, bathroom/toilet facilities and communal areas. All areas viewed appeared clean and tidy and in keeping with a homely environment. Fixtures and fittings and general decoration were seen to be of a good standard. The house was homely and central to amenities. The number of toilet and bathroom facilities provided by the Home meets current required standards. Toilets and bathrooms were lockable offering service users’ privacy, although staff are able to access toilets/bathrooms in an emergency if required. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 18 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): 33,34,35 Quality in this outcome group is poor. Service users can not always feel confident that their needs are fully supported at all times of the day. Whilst the standard of care evidenced at the inspection was found to be sound staff do not all have the training and skills necessary to carry out their duties on evidence seen at time of inspection. Service users are not fully protected by the recruitment procedures within the home. EVIDENCE: From discussions with the Owner at Mariner Folly observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the service users needs. However is was identified that at busy times of the day in the judgement of the inspector not enough staff were found to be on duty between 7:30AM and 9:00AM. The owner confirmed that she would review staffing arrangements and include in the home’s action plan on how any shortfalls would be addressed. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 19 The inspector viewed details of the home’s recruitment procedure and a number of records relating to staff members recruited. Not all the files contained two references, proof of identity, confirmation of work status and all the information as required under schedule 2 of the Care Home Regulations 2001. The home needs to show that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of I.D and copies of qualification certificates, seeks two written references, confirms work status and also undertakes some telephone checks and retains all the information as required under schedule 2 of the Care Home Regulations 2001. The majority of staff have received training in the following. Fire safety awareness, Adult protection, First Aid, Basic food Hygiene, Manual Handling, health and safety, Administration of Medication. However this was not the case for all staff. On evidence seen only five staff have completed an NVQ Level II in Care or above. The home needs to demonstrate that the staff have the training and experience to carry out their role’s and meet with regulation 18 of the Care Home Regulations 2001 The owner was unable to confirm that the induction met with the standards with regard to standard 35.3 and that such induction training took place within six weeks of appointment followed by foundation training (within six months of appointment) to Sector Skills Council specifications. The home was requested to review its core and induction training to ensure that it meets with standard 35.3 and with current guidance and requirements. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 20 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): 37,42 Quality in this outcome group is adequate Whilst the quality of care offered to service users is on the whole sound, it will be better promoted once a full-time Registered Manager is appointed to run the home. Service users health and safety is at risk due to the home’s failure to evidence that the home meets with all legal health and safety requirements. EVIDENCE: The home currently does not have a Registered Manager. The management of the home is supported by the owner. The home was requested to include in the home’s action plan on how compliance would be achieved. The inspector viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The inspector viewed the Fire Log book, which was on the whole up-to-date. The inspector was unable to Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 21 fully evidence that checks and servicing of equipment etc had been undertaken at the required frequency due to the lack of paperwork. COSH (containment of substances hazardous to health) assessments and data sheets were available along with risk assessments. Procedures are available for the reporting of accidents and incidents (Regulation 37) along with detailed risk assessments for the home. Staff training was not however fully evidenced with regard to First Aid, Food Hygiene and other mandatory courses. The home was requested to review standard 42 of the National Minimum Standards for Younger Adults to ensure that it meets with said standards and has evidence available of compliance at time of inspection. Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 22 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 3 2 1 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 1 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 2 34 2 35 2 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 3 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x x x x 2 x Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 14(1) Requirement 14.—(1) The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— (a) the needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; (d) the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. (2) The registered person shall ensure that the assessment of the service user’s DS0000050495.V292186.R01.S.doc Timescale for action 15/12/06 Mariners Folly Version 5.1 Page 24 2 YA66 15(1) 3 YA9 13(4) 4 YA20 13(2) 5 YA22 22(1) needs is — (a) kept under review; and (b) revised at any time when it is necessary to do so having regard to any change of circumstances. 15.—(1) Unless it is impracticable to carry out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met. 13.—(4) The registered person shall ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, 13.—(2) The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. Regulation 17(1)(a) Schedule 3 (k) a record of all medicines kept in the care home for the service user, and the date on which they were administered to the service user; 22.—(1) The registered person shall establish a procedure (“the complaints procedure”) for considering complaints made to DS0000050495.V292186.R01.S.doc 15/12/06 15/09/06 15/08/06 15/09/06 Mariners Folly Version 5.1 Page 25 6 YA23 13(6) 8 YA34 19(1) the registered person by a service user or person acting on the service user’s behalf. (2) The complaints procedure shall be appropriate to the needs of service users. (3) The registered person shall ensure that any complaint made under the complaints procedure is fully investigated. (4) The registered person shall, within 28 days after the date on which the complaint is made, or such shorter period as may be reasonable in the circumstances, inform the person who made the complaint of the action (if any) that is to be taken. (5) The registered person shall supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so requests. (6) Where a written copy of the complaints procedure is to be supplied in accordance with paragraph (5) to a person who is blind or whose vision is impaired, the registered person shall so far as it is practicable to do so supply, in addition to the written copy, a copy of the complaints procedure in a form which is suitable for that person. 13.—(6) The registered person 15/09/06 shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 19.—(1) The registered person 15/09/06 shall not employ a person to work at the care home unless— (a) the person is fit to work at the care home; (b) subject to paragraph (6), he DS0000050495.V292186.R01.S.doc Version 5.1 Page 26 Mariners Folly 9 YA35 18(1) 10 YA42 12(1) has obtained in respect of that person the information and documents specified in— (i) paragraphs 1 to 6 of Schedule 2; 18.— (1) The registered person 15/12/06 shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users; (b) ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs; (c) ensure that the persons employed by the registered person to work at the care home receive— (i) training appropriate to the work they are to perform; 12.—(1) The registered person 15/09/06 shall ensure that the care home is conducted so as— (a) to promote and make proper provision for the health and welfare of service users; Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone 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 Mariners Folly DS0000050495.V292186.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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