Inspection on 03/07/07 for Mariners Folly

This inspection was carried out on 3rd July 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mariners Folly 29/12/06

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 3rd July 2007 8:00 Mariners Folly DS0000050495.V343180.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.V343180.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.V343180.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.V343180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. The range of fees charged for services provided range from £506 to £532 per person per week. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector agreed and explained the inspection process with the manager present during the inspection. The focus of the inspection was to assess Mariners Folly in accordance with the Care Home Regulations 2001 and 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 used a triangulated methodology to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider was used in the planning process to ensure hypotheses were formulated to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an annual quality assurance assessment questionnaire which was received prior the site visit to the home. This provided the Inspector with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. Survey questionnaires were sent to the home prior to the inspection. 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. Other area’s viewed included risk assessments, pre-admission assessments, menus, rota’s, training records and recruitment records. In addition a full environmental tour took place. The Inspector identified two Residents for case tracking, speaking with one of them and assessing the available information held in the home pertaining to the care provision for both. In addition the Inspector met with the other Residents, which gave him a good opportunity to observe the quality of care within the home and activities enjoyed. What the service does well: It is evident through the inspector talking to members of staff that the emotional health of the residents is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. The home is to be commended on its work in producing a communications passport / workbook that explores with the resident area’s of their lives that they wish to influence and change. This is completed by the resident as their capacity and understanding allows to further reinforce their own personal sense of ownership of their plan of care and rights of citizenship. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Mariners Folly DS0000050495.V343180.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.V343180.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): 1,2,3,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have the information they need to ascertain whether the home can meet their needs in a format they can understand. Residents’ rights are protected by a written contract. Prospective residents also have the benefit of a trial period at the home. Residents can be confident that their needs will be properly assessed prior to moving to the home. EVIDENCE: The Statement of Purpose and residents’ guide for Mariners Folly has been redrafted and updated and now contains all the information required as per schedule 1 of the care Home Regulations 2001 as confirmed by the manager. The manager had also produced the residents’ guide in a format that the residents could more easily understand. It was suggested by the inspector that the service user guide could be further expanded and include more familiar pictures and photographs of the home. The manager reported that a copy of the previous inspection reports are made available to residents and their families. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 9 A written contract / statement was available outlining residents’ rights, responsibilities, and conditions of placement is in place. Each service user has been provided with a copy. Records held showed that residents have an assessment which identifies their individual needs prior to or on admission to the home. The information is provided by the residents, their families and health / social care professionals. This is then reflected into the care plans and these are developed in agreement with the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Prospective Residents have the benefit of a trial period at Mariners Folly to assess whether the home can or cannot meet their needs. Mariners Folly DS0000050495.V343180.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from having clear individual plans that are comprehensive, identify their needs and are specific to the individual service user. However further detail that residents are fully involved in the process and contribute towards setting their hopes aspirations and goals needs to be evidenced. Care plans showed that residents are enabled to make decisions and choices. Residents are enabled to take responsible risks. However this was not fully documented which potentially put the residents at risk. EVIDENCE: The home and its staff are committed to supporting the residents. This was evidenced through the care plans which detailed the areas of support that the resident needed and how this support is provided by the staff. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 11 There were guidelines in respect to routines and behaviour. The member of staff confirmed that these are reviewed with the residents on a regular basis and the families are supported to be involved where possible. The inspector requested that care planning is reviewed to further evidence that residents are fully involved in the process and contribute towards setting their hopes aspirations and goals. The home is to be commended on its work in producing a communications passport / workbook that explores with the resident area’s of their lives that they wish to influence and change. This is completed by the resident as their capacity and understanding allows to further reinforce their own personal sense of ownership of their plan of care and rights of citizenship. It was the opinion of the inspector that more innovative methods could be considered to further enable residents to participate and communicate their views to the development of their care plan and the review process. The plan focuses on current needs, development of skills. This follows the principles of person centred planning. Staff have the necessary training and skills to support and encourage the individual to be fully involved. Where residents have limited communication, staff are skilled in using other methods of engagement. A key worker system provides additional support enabling one to one involvement. Residents rights to make decisions are respected and the care plans reflected their ability to make an informed judgement. Plans sampled demonstrated that the home used positive planned interventions to manage residents’ behaviour. Records kept of service users monies were seen to have been improved since the last inspection and the inspector was able to track expenditure from the records sampled and therefore the system was less open to abuse. However in the opinion of the inspector the system of record keeping could be improved further to ensure that all the money is accounted for especially at shift handovers. Care plans did not include a comprehensive risk assessment for each area of risk. Risk assessments were seen as being of variable quality and not reviewed on a regular basis. Management of risk needs to take into account the specialist needs, balanced with their aspirations for independence, choice, normal living and personal relationships. Any limitations needs to be fully documented and reviewed on a regular basis to ensure their ongoing relevance. Mariners Folly DS0000050495.V343180.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): 12,13,14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents can be confident that they are offered a range of opportunities for personal development and to learn new skills and feel part of the wider community. Residents engage in a good level of activities which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. EVIDENCE: Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 13 Residents are enabled to participate and contribute to meeting their own self care needs and day to day chores around the house. Since the last inspection staffing levels have been reviewed and increased at peak times to facilitate activities. Discussion with staff and residents confirmed that the level of activities were of a good level and that they enjoyed stimulation through leisure and recreational activities both inside and outside the home. Evidence of this was seen from discussion and records kept within the home. The inspector joined residents at 8:00am while they were getting ready for the day ahead. The inspector had the opportunity to speak to several of the residents who expressed their opinion of the home and the activities they participated in and enjoyed. Other residents were observed participating and interacting with staff. Residents 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. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents 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. However no fresh fruit was available at time of inspection or fresh vegetables, although the manager was out when the inspector first arrived carrying out food shopping. The manager was requested to ensure that fresh fruit and vegetables were available more often and shown more prominently on the menu. No statutory requirement has been made at this time. Mariners Folly DS0000050495.V343180.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal support was not inspected on this occasion. However this standard was met at the last inspection and no evidence since that inspection has suggested otherwise. Therefore residents continue to feel supported by the level of help given. Medication was not inspected on this occasion. However this standard was met at the last inspection and no evidence since that inspection has suggested otherwise. Therefore residents can continue to feel confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. EVIDENCE: Personal support was not inspected on this occasion. However this standard was met at the last inspection and no evidence since that inspection has suggested otherwise. Therefore residents continue to feel supported by the level of help given. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 15 The care plans also fully documented all physical and emotional healthcare needs and where able Residents filled in or were supported to fill in appropriate forms. Within the care plans records of health care provided by G.P, chiropodist, dentist, and opticians was evident. Residents physical and emotional health is monitored on a daily basis. Through their daily records and these correspond with support assessments held in the care plans. This system ensures that all Residents receive continuity of care and supports potential complications and problems at an early stage. It is evident through records that the emotional health support is of a high priority to this home and the staff are pro-active in maintaining and supporting Residents with their emotional needs in order to maintain their quality of life. Medication was not inspected on this occasion. However this standard was met at the last inspection and no evidence since that inspection has suggested otherwise. Therefore residents can continue to feel confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. Mariners Folly DS0000050495.V343180.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents know that their concerns and complaints are taken seriously and are protected from the risks of abuse. EVIDENCE: A copy of Mariners Folly complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. The home was recommended to make the complaints procedure more widely distributed, and highly visible within the service and make is more readily available in different formats. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. No requirement has been made at this time. The home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure was discussed. 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. Full training is provided in adult protection. The home promotes an open culture where residents feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding protection are in place. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 17 The home ensures through training, supervision, review and quality monitoring that care staff fully comply with the policies and procedures provided in relation to protecting and safeguarding the rights of people who use the service. Criminal Record Bureau Checks (CRB) have been obtained for all staff. Mariners Folly DS0000050495.V343180.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): 24,25,27,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home which is suitable for their needs. Residents cannot feel confident that all part of the home at kept clean to a high standard. EVIDENCE: The Inspector undertook a tour of the home including some residents’ rooms, with their permission, bathroom/toilet facilities and communal areas. Fixtures and fittings and general decoration were seen to be of a good standard. Bedrooms were seen to be personal in nature with each resident expressing their own identity. The number of toilet and bathroom facilities provided by the home meets current required standards. Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 19 The home is not always clean and tidy, domestic cleaning arrangements are not adequate. Parts of the kitchen including food cupboards were found to be dirty with open packets of food not stored properly. This was seen to raise the risk of an outbreak of infection. The shower in one of the bathrooms was also found to be dirty. The home was requested to review its infection control and food hygiene measures and seek advice from the Environmental Health Officer and the NHS control of infection team. The management has not recognised or responded to these and the risk to residents harming themselves is high. Mariners Folly DS0000050495.V343180.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): 32,33,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ care, social and emotional needs are promoted by the employment of caring staff in such numbers to meet their needs. Residents cannot feel fully confident that staff are trained to the required standard. Residents are protected from potential abuse by the home’s staff recruitment procedures. EVIDENCE: From discussions with the Manager, observations and reviewing the staff rotas more than sufficient staff were on duty at the time of inspection to meet the residents needs. The home provides on a Monday, Wednesday, and Fridays four Am staff and three Pm staff. On a Tuesday, Thursday, Saturday and Sunday three AM and three PM. Additionally one night staff and a member of staff who sleeps in to Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 21 provide emergency cover also work every night. The manager is also available Monday to Friday should the staff need additional support. The inspector was informed that staffing numbers would be reviewed and staff increased should the needs of the service users change long term. The inspector requested that the managers hours are also shown The service recognises the importance of training, and tries to deliver a programme that meets any statutory requirements and the National Minimum Standards. The manager is aware that there are some gaps in the training programme and plans to deal with this. The service is also able to recognise when additional training is needed, but is not always in a position to provide this training. Shortfalls were noted in key core area’s including Manual handling, health and safety, non violent crisis intervention and food hygiene. The manager was requested to address the shortfalls as a priority. Due to staff changes presently out of a staff team of nine only two have a NVQ Level 2 in Care. The required standard was 50 of the staff by 2005 which would equate to four staff. The manager is aware of the shortfall and confirmed that this shortfall would be addressed. The manager confirmed that the induction programme adopted complies fully with the recommendations of the Skills for Care Councils current guidance. The inspector viewed details of the Home’s recruitment procedure and a number of records relating to staff members recruited. The Home 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 written references. All staff appointments are subject to a probation period, which is subject to review. All staff have a contract of employment and job description. Mariners Folly DS0000050495.V343180.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): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents on the whole benefit from living in a well run and managed home. Residents and or their relatives cannot be fully confident that their views and opinions effect how the home is run and that their best interest are safeguarded by an effective quality assurance system. Residents can feel confident that their health and safety/ welfare is protected by robust policies/ procedures and safety checks. EVIDENCE: Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 23 The manager is qualified and has the necessary experience to run the Home; she is aware of, and works towards achieving the basic processes set out in the National Minimum Standards. The manager and staff have worked hard to improve standards within the home. This was evident from the significant reduction in the number of statutory requirements from the last inspection. The manager now has more time to attend to improving standards and managing the home and does not generally work on shift supporting residents. The manager recognises that more work is needed to improve standards in some areas and is confident that the identified shortfalls will be addressed. The home has a Statement of Purpose that sets out the aims and objectives of the service. The manager is improving and developing systems that monitor practice and compliance with the homes plans, policies and procedures. More work is needed in this area. 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. The policy and procedure that related to quality assurance made reference to complying with ISO 9000 and ISO 9001. ISO 9000 is a family of standards for quality management systems which is maintained by ISO, the International Organisation for Standardisation and is administered by accreditation and certification bodies. The home is not accredited to this organisation and therefore this policy is inacurate and not relevent to the home. The home was requested to review this policy to ensure its relevence and review its compliance with standard 39 of the National Minimum Standards. The home has a full range of policies and procedures to promote and protect Residents’ health and safety. There is full and clearly written recording of all safety checks and there is no evidence of a failure to comply with other legislation. There is a good understanding of risk assessment and this is taken into account in all aspects of the running of the home. The quality assurance system confirms that the findings from risk assessments have been actioned and the home continuously improves its systems for health and safety. The manager however needs to ensure that all staff are trained in health and safety matters and have regular planned updates. A statutory requirement has been made in respect of training. Mariners Folly DS0000050495.V343180.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 2 33 3 34 3 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 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 1 x x 3 x Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15(1) Requirement The home shall develop a plan of care that evidences the involvement of residents, includes their hopes, aspirations and goals and how these will be achieved where possible. Action is taken to minimize identified risks and hazards, and service users are given training about their personal safety, to avoid limiting the service user’s preferred activity or choice. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall, 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. The registered person shall establish and maintain a system for (a) reviewing at appropriate intervals; and DS0000050495.V343180.R01.S.doc Timescale for action 03/09/07 2 YA9 13(4) 03/09/07 3 YA30 13(1)(3) 03/08/07 4 YA32 18(1) 03/01/08 5 YA39 24(1) 03/01/08 Mariners Folly Version 5.2 Page 26 (b) improving, the quality of care provided at the care home., (2) The registered person shall supply to the Commission a report in 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. 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.V343180.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mariners Folly DS0000050495.V343180.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!