Inspection on 29/12/06 for Mariners Folly

This inspection was carried out on 29th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 18 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 15/06/06

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 29th December 2006 1:00 Mariners Folly DS0000050495.V325646.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 Mariners Folly DS0000050495.V325646.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. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 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 Post Vacant Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2006 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. 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.V325646.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started on 29th December 2006 at 1:00pm and was concluded on the 3rd January 2007 at 5:00pm. The inspector was accompanied by a senior care manager from Dartford Social Services for part of the inspection on the 29th December 2006. The Inspector agreed and explained the inspection process with the manager 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 inspector spent time explaining the new inspection process to the manager and gave her information booklets on Health and safety in Care Home’s, Improving the systems that safeguard adults living in a care home, The qualities people expect from care services and recruitment of care staff. The home does not have a registered manager in post at present. A newly appointed manager is currently overseeing the management of the home. Time was also spent by the inspector observing and talking to service users and staff discussing the standard of care within the home. Many standards inspected during this inspection remain outstanding from the previous inspection. Failure to address these shortfalls within the timescales could result in formal legal enforcement under the Care Home’s Regulations 2001. The home has expressed a wiliness to work with the Commission and it is hoped that standards of care within the home will improve. The home has demonstrated many positives and a number of the outcomes for standards were judged as good. The range of fees charged for services provided range from £485 to £520 per person. What the service does well: Service users can be confident on the whole that they are offered opportunities for personal development and to learn new skills and feel part of the wider community and engage in a level of activities which are appropriate to their needs. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 6 Service users are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. 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. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 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.V325646.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate Prospective service users continue not have all the information they need to make an informed choice about whether they wish to live at the home following the last inspection. Service users cannot feel fully confident that their needs will be suitably assessed and that the assessment process meets with the standards. Whilst service users have been issued with a contract they do not currently meet the National Minimum Standards. EVIDENCE: The new manager has since joining the home prepared a new service user guide in a more easily understood format and is commended for her work. This was however seen as a work in progress document as this and the statement of purpose was found not to include all the information as required of Schedule 1 of the Care Home Regulations 2001and standard 1.2 of the National Minimum Standards for Younger Adults. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 9 Documentation available to service users needs to show that it clearly sets out the objectives and philosophy of the service supported by a Service user Guide. The guide should detail what the prospective individual can expect and gives a clear account of the specialist services provided, quality of the accommodation, qualifications and experience of staff, a complaint procedure that meets with the standards, recent CSCI inspection findings and contains comments and experiences of residents living at the home. All residents should be given a copy of the Guide. When requested the service needs to show that it can provide a copy of the SOP and guide in a format which will meet the capacity of the service users where possible. The manager agreed to do address this and include in the home’s action plan. The manager has recently introduced a new assessment process within the home to ensure that the needs of any prospective service users are matched with the services offered by the home. The inspector was unable to evidence if the assessments contained all of the information needed to make an informed decision as whether the home would be able to meet the prospective service users needs as the information was not available The manager was requested to review this process to ensure that it follows the standards with regard to standard 2 The home is expected to be accountable for delivery of promised services under a written contract between the care home and the service user which sets out the terms and conditions of residency and service provision and the rights and responsibilities of both parties. Therefore the Inspector requested that the manager review its contract / statement of terms and conditions to ensure that it contains all of the elements as per standard 5. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate Not all service users benefit from having clear and in-depth care plans that identify their individual needs, aspirations and goals and gives clear guidance to staff. Service users cannot feel confident that records relating to their own personal monies are correctly accounted for and that appropriate auditable records kept. Service users cannot feel confident that they are supported to take risk within a risk management framework. EVIDENCE: The inspector viewed and discussed with the manager the care records relating to several service users. The manager has recently joined the home and is Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 11 currently working to update the care planning system to ensure that they clearly show the service users needs and how they should be supported. Therefore only a few of the care plans have currently been updated. In the care plans viewed there were clear guidelines in respect to support needed with regard to strategies to manage and support service users with their needs. The home undertakes regular reviews. Formal reviews involving significant professionals and relatives where possible are also undertaken. No evidence however 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, although they are invited to their review should they wish to attend. The care planning system needs to show that it puts the individual at the centre of service delivery by the care home. The Plan should reflect all the needs, aspirations and goals of the individual, set out the services to be provided by the care home to meet needs and achieve goals, and develop as the service users life and circumstances change. The inspector first visited the home on two separate days. 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 staff on duty at the times of inspection had 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. Records kept of service users monies were seen to be very poor. The inspector was unable to track expenditure from the records sampled and therefore the system was open to abuse. The inspection requested that this shortfall was addressed as a priority. Risk assessment were seen to be poor within the home’s care planning system. The manager recognises this and is committed to ensure that all service users have comprehensive risk assessments to minimise risk. Management of risk needs to take into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made following consultation with the service user, relative where appropriate and social services care management. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,16,17 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is good Service users can be confident on the whole that they are offered opportunities for personal development and to learn new skills and feel part of the wider community and engage in a level of 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. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 13 EVIDENCE: Service users are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house although as previously evidenced this was not reflected in the care plan. Discussion with the manager and staff confirmed that the level of activities were of a good quality overall for the more able independent service users and that they enjoyed a good level of stimulation through leisure and recreational activities both inside and outside the home. This however this was not the experience of all of the service users. The inspector commented that the outcomes for all service users should be the same regardless of ability. The Inspector requested that the home detail within the home’s action plan how it will be evidenced that all service users have the same opportunities The inspector spent time and spoke to service users about their activities within the home. They confirmed that service users have been enabled to and encouraged to participate in hobbies and activities which they had an interest in, such as maintaining and building on personal collections and specific recreational activities including watching video’s. It was confirmed that service users are enabled to maintain contact with relatives and friends where they wished to do so. Examples of such included provision for relatives and friends to visit the home and support being provided to enable services users to visit relatives or friends outside the home. 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. From observation, 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 with staff support should they wish. Service users on evidence seen have had been involved in planning and choosing menus. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is good Service users feel supported by the level of help given and that their healthcare needs are addressed. Service users can feel confident that they are supported by the home’s policy and procedures for storing and administering 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. Service users were able to make their own choice where possible with regards to what they wished to wear and their hairstyles and this was evident by their individual appearance. The inspector observed excellent interaction between staff and Service users. Staff actively promote the service users right of access to the health and remedial services that they need, both within the home and in the community. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 15 Regular appointments are seen as important and there are systems in place to make sure residents are reminded and appointments are not missed. This system ensures that all service users receive continuity of care and support and that potential complications and problems are recognised and dealt with at an early stage. However records were seen not to have been kept up to date and in need of reviewing by the manager to ensure that accurate records are kept. The manager reported that at the time of the inspection one service user was undertaking management of his own medication. The room used to store the medication was found to be suitable. The Home uses a Monitored Dosage System. 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. The manager informed the Inspector that all staff administering medication have completed the necessary training. The inspector noted significant improvement in the record keeping recording and storage of medication within the home. Responsibility for ensuring that staff follow correct procedures and that policies are followed is monitored by one member of staff within the home who is to be commended. The inspection of the medication confirmed that Prn or as required medication protocols are written up for all Prn medication. The MAR sheets (drug record sheets) were seen as being completed properly and the medication stored appropriately. The manager was requested to update the home’s medication policy and ensure that the temperature of the medication cabinet is recorded regularly. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is adequate. Service users rights with regard to making a complaint and whom to complain to are compromised due to the home not having a complaints procedure in place that meets with the National Minimum Standards. Service users are potentially at risk of abuse due to the lack of policies and procedures that are in line with current practice and follow Adult Protection protocols. EVIDENCE: A copy of the home’s complaints procedures was available within the home and has been made available in a format that service users could understand. However it did not contain of the required elements as per the standards. The inspector also recommended that the home introduce a low - level complaints book to enable the home to monitor concerns raised by the service users. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 17 The home’s Policy for the Protection of service users and staff “Whistle blowing” procedure was discussed and viewed. These 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. Both of these policies are in need of being reviewed and were found to be inaccurate with regard to following the latest guidance. Full training however has been provided in adult abuse for all staff. The home did possess a copy of the Kent and Medway Adult Protection and Child Protection procedures / Protocols. The manager was requested to update its policies and procedures ensure that all staff are aware of these policies and update its complaints procedure. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is adequate. Service users benefit from living in on the whole clean comfortable home, which is suitable for their needs. Service users are at possible risk because of the poor infection control measures used in the home. EVIDENCE: The Inspector undertook a tour of the home including viewing some service users rooms, bathroom/toilet facilities and communal areas. All areas viewed appeared clean with the exception of one of the bathrooms. Fixtures and fittings and general decoration were seen to be of a variable quality with damp penetrating some of the service users bedrooms. Many light bulbs were missing thus making some part of the home look dim and uncared for. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 19 Some remedial work was seen as being needed due to the demands placed on the building by the service user group and further decoration of rooms to make the home appear more homely. The manager agreed that some re-decoration was needed with the service users input and would include it within the home’s action plan. The home enables service users to live in a discrete non- institutional environment. Service users are fully involved in decisions about the décor of their own rooms. Individuals personalise their rooms and bring in their own furniture if they wish. All bedrooms enable privacy and have locks on the doors residents have control and ownership of their own space. All residents have keys to their rooms unless a risk assessment indicates otherwise. They also have a key to the front/outer door where this has been agreed. There is a selection of communal areas in the home, this means that service users have a choice of place to sit quietly, meet with family and friends or be actively engaged with other people who use the service. The home does not have an on-going maintenance programme in place. Essential maintenance is only done when a problem has already arisen. A number of the fixtures and fittings need replacing and some of the décor requires upgrading. There have not been any outbreaks of infection. However service users are at risk due to the failure of the home to follow infection control procedures. Mops were found not to be colour coded to signify use and were not stored to promote hygiene and compliance with infection control guidance. The home was requested to contact the NHS Control of Infection Team for advice and guidance. It was evidenced on the first day of inspection that service users were at risks due to unguarded electrical wires being exposed in two of the bathroom and excessively hot water in some of the bedrooms. The management had not recognised or responded to these and the risk to service users harming themselves is high. Health and safety is further covered in more detail later in the report. Mariners Folly DS0000050495.V325646.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is poor Service user’s care, social and emotional needs are not fully promoted by the employment of staff in numbers that support all their individual needs. Service users cannot always feel confident that they are supported by staff who are fully trained to meet their needs. EVIDENCE: From discussions with the manager, observations and reviewing the staff rotas insufficient staff were on duty at the time of inspection and other times to fully meet all the service users needs. The home provides a ratio of three members of staff on each shift during the day and evening with two members of staff on duty at night one who is the sleep-in (sleeps at the home in the event of difficulties / emergencies). The inspector was informed at the inspection that two members of staff had recently handed in their notices and were due to leave. It was evidenced that Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 21 the manager increasingly has to spend more time covering shifts herself thus not allowing her time to fully manage the home. It was the judgement of the inspector that taking into account holidays and any future sickness this would put a great deal of strain on the managers ability to run the home in such a way that would not compromise safety and quality of care. Many shifts were seen to be uncovered when the inspector viewed the rota. As evidenced whilst talking and observing service users not all of them have opportunities to fully access the community and have meaningful activities due to understaffing and staff shortages. The home was requested to urgently review its staffing and take appropriate steps to increase staffing numbers to meet the needs of the service users. The recently appointed manager has taken steps to improve staff training within the home and has prepared a training matrix and identified what training is needed. This process is currently ongoing. Therefore currently staff have not undertaken all of the required training / updates to maintain qualifications. The home was also unable to evidence that all staff receive structured induction training (within six weeks of appointment) and foundation training (within six months of appointment) to Sector Skills Council specification (including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting). 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 and provide an action plan with regard to ensuring that the home provides suitably trained staff as per the requirements of regulation 18 of the Care Home Regulations 2001. Mariners Folly DS0000050495.V325646.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 This judgement has been made using available evidence including a visit to this service. Quality in this outcome group is poor Service users on the whole do not benefit from living in a well run and managed home. Service users and or their relatives cannot be fully confident that their views and opinions effect how the home is run and that their best interests are safeguarded by appropriate policies and procedures. Service users cannot feel fully confident that their health and safety/ welfare is protected by robust policies/ procedures and safety checks. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home now benefits from having a new manager who is sufficiently qualified and experienced to carry out her role. During the inspection process it was evident that she is aware of the home’s shortfalls and has expressed a wiliness to work with the Commission to raise standards within the home and meet with the National Minimum Standards. However due to staffing difficulties the manager has had to spend more time working with and directly supporting service users and has less time to improve standards in the home. The inspector requested that within the home’s action plan the registered provider and the manager address how these concerns will be managed to ensure an improvement in standards. The home operates a keyworker system to identify an individual staff member to directly to work with a service user on a one to one basis. The home has developed a service user quality assurance questionnaire which will be shortly introduced within the home. Therefore at present the home was evidenced as not meeting the required standard with regard to quality assurance. One member of staff assisting with the inspection stated that they were not aware if the home had policies and procedures for all topics set out in Appendix 2 of the National Minimum Standards, Care Home Regulations. The manager was made aware of this. Adult protection and whisleblowing policies were found to be out of date and not following national guidance. The manager stated that all policies would be reviewed to ensure compliance. During a tour of the building the inspector noted bare electrical wires exposed within two bathrooms and broken handrail within one of the baths that could cause significant injury. The inspector commented that any hazard that poses an unacceptable risk to health and safety must be actioned as a priority. The inspector further requested that remedial work is actioned before the inspector left the building to ensure safety to service users. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 24 The inspector viewed records relating to staff training, Health and Safety Procedures, maintenance and servicing, and risk assessments, which were discussed with the manager. Staff training requirements had been identified and arrangements for staff to undertake the required training relating to health and safety. The inspector was unable however to evidence that the home had a Fire Log book, reflecting that checks and servicing of fire safety equipment had been undertaken at the required frequency. The manager was requested to contact the fire officer to ensure that one was in place and ask for advice with regard to the fire escapes which allowed access to service users which could pose a risk. Environmental risk assessments were not in place. Problems had been identified with the heating system which was seen to be ongoing by the inspector. Water temperatures were also seen to be both excessively cold and hot within the home. The inspector evidenced that temperatures ranged from 12 degrees Celsius to 60. An urgent action plan addressing concerns with the heating system was requested, which has now been received by the Commission prior to writing this report. Such inspection has now been requested. Procedures are available for the reporting of accidents and incidents (Regulation 37) and records maintained of the same. However not all incidents had been reported. The home was able to evidence that COSH (Containment of Substances Hazardous to Health) assessments and data sheets were in place, however chemicals were found being stored in an open cupboard at the top of the house. The home was requested to review standard 42 of the National Minimum Standards for Younger Adults to ensure that it meets with said standard and evidence with the action plan how compliance will be achieved. Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 25 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 2 2 2 3 x 4 x 5 2 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 2 25 x 26 x 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 2 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 2 14 2 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x x 2 1 1 x 1 x Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 26 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(1) 5(1) Requirement 4.—(1) The registered person shall compile in relation to the care home a written statement (in these Regulations referred to as “the statement of purpose”) which shall consist of— (a) a statement of the aims and objectives of the care home; (b) a statement as to the facilities and services which are to be provided by the registered person for service users; and (c) a statement as to the matters listed in Schedule 1. (2) The registered person shall supply a copy of the statement of purpose to the Commission and shall make a copy of it available on request for inspection by every service user and any representative of a service user. 5.—(1) The registered person shall produce a written guide to the care home (in these Regulations referred DS0000050495.V325646.R01.S.doc Timescale for action 29/06/07 Mariners Folly Version 5.2 Page 27 to as “the service user’s guide”) which shall include— (a) a summary of the statement of purpose; (b) the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; (c) a standard form of contract for the provision of services and facilities by the registered provider to service users; (d) the most recent inspection report; (e) a summary of the complaints procedure established under regulation 22; (f) the address and telephone number of the Commission. (2) The registered person shall supply a copy of the service user’s guide to the Commission and each service user. provider, manager and staff; 2 YA2 14(1) 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 DS0000050495.V325646.R01.S.doc 29/06/07 Mariners Folly Version 5.2 Page 28 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 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. 3 YA5 5(1) 5.—(1) The registered person shall produce a written guide to the care home (in these Regulations referred to as “the service user’s guide”) which shall include— (a) a summary of the statement of purpose; (b) the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees; (c) a standard form of contract for the provision of services and facilities by the registered provider to service users; (d) the most recent inspection report; (e) a summary of the complaints procedure established under regulation DS0000050495.V325646.R01.S.doc 29/06/07 Mariners Folly Version 5.2 Page 29 22; (f) the address and telephone number of the Commission. (2) The registered person shall supply a copy of the service user’s guide to the Commission and each service user. provider, manager and staff; 4. YA6 15(1) 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. 17. - (1) The registered person shall (a) maintain in respect of each service user a record which includes the information, documents and other records specified in Schedule 3 relating to the service user; (b) ensure that the record referred to in sub-paragraph (a) is kept securely in the care home. (2) The registered person shall maintain in the care home the records specified in Schedule 4. (3) The registered person shall ensure that the records referred to in paragraphs (1) and (2) (a) are kept up to date; and (b) are at all times available DS0000050495.V325646.R01.S.doc 29/06/07 5 YA7 17(1) 29/03/07 Mariners Folly Version 5.2 Page 30 for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. (4) The records referred to in paragraphs (1) and (2) shall be retained for not less than three years from the date of the last entry. 6. YA9 13(4) 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, 29/03/07 7 YA13 YA14 16(1)(2)(m,n) 16. - (1) Subject to 29/01/07 regulation 4(3), the registered person shall provide facilities and services to service users in accordance with the statement required by regulation 4(1)(b) in respect of the care home. (2) The registered person shall having regard to the size of the care home and the number and needs of service users (m) consult service users about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or DS0000050495.V325646.R01.S.doc Version 5.2 Page 31 Mariners Folly communicate with, their families and friends; (n) consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. 8 YA19 13(1) 13. - (1) The registered person shall make arrangements for service users (b) to receive where necessary, treatment, advice and other services from any health care professional. 29/03/07 9 YA22 22(1) 29/03/07 22.—(1) The registered person shall establish a procedure (the complaints procedure) for considering complaints made to 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 DS0000050495.V325646.R01.S.doc Version 5.2 Page 32 Mariners Folly 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. 10 YA23 13(6) 13.—(6) The registered person 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. 29/03/07 11 YA24 23(1)(2) 23. - (1) Subject to 29/06/07 regulation 4(3), the registered person shall not use premises for the purposes of a care home unless (2) The registered person shall having regard to the number and needs of the service users ensure that (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; Mariners Folly DS0000050495.V325646.R01.S.doc Version 5.2 Page 33 (c) equipment provided at the care home for use by service users or persons who work at the care home are maintained in good working order; 12 YA30 13(1)(3) 13. - (1) The registered person shall make arrangements for service users (3) The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. 18. - (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users 29/03/07 13 YA32 YA35 18(1) 29/03/07 14 YA38 12(1) (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; 12. - (1) The registered 29/03/07 person 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; (b) to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. (2) The registered person shall so far as practicable enable service users to make decisions with respect to the DS0000050495.V325646.R01.S.doc Version 5.2 Page 34 Mariners Folly care they are to receive and their health and welfare. (3) The registered person shall, for the purpose of providing care to service users, and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. (4) The registered person shall make suitable arrangements to ensure that the care home is conducted (a) in a manner which respects the privacy and dignity of service users; (b) with due regard to the sex, religious persuasion, racial origin, and cultural and linguistic background and any disability of service users. (5) The registered provider and registered manager (if any) shall, in relation to the conduct of the care home (a) maintain good personal and professional relationships with each other and with service users and staff; and (b) encourage and assist staff to maintain good personal and professional relationships with service users. 15 YA39 24(1) 24. - (1) The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and (b) improving, the quality of care provided at the care home., (2) The registered person shall supply to the Commission a report in DS0000050495.V325646.R01.S.doc 29/06/07 Mariners Folly Version 5.2 Page 35 respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. (3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. 18 YA42 12(1) 12.—(1) The registered person 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; 29/03/07 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.V325646.R01.S.doc Version 5.2 Page 36 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. 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