Inspection on 13/02/06 for Osborne Court

This inspection was carried out on 13th February 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Osborne Court 30/05/07

Osborne Court 03/05/06

Osborne Court 31/07/05

Osborne Court 14/10/04

Osborne Court 04/05/04

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

CARE HOME ADULTS 18-65 Osborne Court Lower Road Faversham Kent ME13 7NT Lead Inspector Kim Rogers Announced Inspection 10:00 13 and 14th February 2006 th Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 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 Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 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. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Osborne Court Address Lower Road Faversham Kent ME13 7NT 01622 671411 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) lyn.henwood@kent.gov.uk Kent County Council Valerie Smith Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2005 Brief Description of the Service: Osborne Court is a two storey detached property set in the grounds of Faversham Day Centre. It is located on the outskirts of Faversham close to the village of Ospringe. There is a large garden with ample parking spaces available. The nearest shops and other public amenities are easily accessible by bus, taxi or the homes own transport. There is a shop within walking distance. The home offers single room accommodation on both floors. Seven rooms on the ground floor can accommodate people with multiple disabilities. The home provides short-term care for people with learning disabilities. Service users can stay from one night to a few weeks. The home aims to provide 24-hour care for adults between the ages of 18-65. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and carried out over two days by one Inspector. Evidence and information was gathered using a variety of methods including written feedback from relatives and service users, talking to relatives, service users and staff during the inspection and making observations. The Inspector also sampled records and had a look around the home. Previously an inspection was carried out on 31/7/05 and 2 further inspections carried out by a Pharmacy Inspector on 23/6/05 and 1/08/05. The pharmacy inspections followed medication errors at the home. Most of the requirements made by the Pharmacy Inspector have been met. An immediate requirement was made at the inspection that the registered person investigates the circumstances surrounding an incident in November 2005. The service user and the Commission should be informed of the outcome of the investigation. There have been some changes in management over the past year or so. Since the previous long term registered manager retired just over one year ago there has been an acting manager in post then a permanent manager then an acting manager. The current acting manager will be at the home until the end of May 2006. The current acting manager, Lyn Henwood is a manager of a KCC day centre and has previous experience of managing Osborne Court on an acting basis. Staff said that there were periods of instability and change but they now feel more stable. During the past few months some systems have been reviewed and changed. The acting manager was unsure about some of the systems and must ensure that systems are in place that not only suit the service users needs and meet the National Minimum Standards but that staff are familiar with and understand. The Inspector received 10 feedback or comments cards from service users and 8 from relatives/ friends. Service users said ‘More activities would be good’ ‘There are no outings and not enough to do’ ‘It can be very noisy’ 7/10 service users said they did not have a key to their room. 5/10 service users said they liked living at the home. Relatives said ‘ I am very satisfied with the care given to my son’ ‘I find the staff very helpful and friendly’ ‘There is a lack of staff’ Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 6 ‘I am very satisfied with how Osborne Court is run’ ‘In common with others I would like to see more activities available’ ‘I’ve always found the staff at Osborne Court very welcoming and friendly’ The Inspector looked at the opportunities for activities and participation in detail. Levels of participation and engagement are low. Both the manager and team leader agreed that this is an area that needs to improve. The Inspector observed staff doing things for service users rather than doing things with service users. Generally this home is safe and provides adequate care to the service users. What the service does well: What has improved since the last inspection? What they could do better: Several areas for development were found. Service users must have opportunities to participate in appropriate activities at the home. Service users must have opportunities to participate in the day-to-day running of the home including everyday household tasks. Using more person centred approaches will improve assessments and support planning. Aspirations must be assessed and supported. Service user plans and risk assessments must be reviewed regularly especially after an accident or incident. Developing individual communication guidelines will increase service users choice and decision-making. Service users views must be sought and listened to and underpin any review and development of the service. Each service user should have a contract detailing the terms and conditions of their stay. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 7 Staff must know when to seek professional advice and support. Improvements to the décor, some furnishings and fittings will enhance service users lives. Locks must be fitted to all bedrooms and service users offered a key. All complaints must be recorded and investigated. All staff must have the required recruitment checks. Staff training and induction records should be at the home. 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. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Prospective service users have the information they need to make a decision about the home. Service users cannot be sure their aspirations will be assessed and supported. Service users are not supported to be aware of their roles and responsibilities. EVIDENCE: Since the last inspection the service user guide has been reviewed and updated. This is given to prospective service users so they have some information about what is on offer at Osborne Court. The Inspector sampled some service user plans. Although service users are referred by care management not all had a care management assessment. The assessment carried out by the home had limited detail. Aspirations, hopes and dreams are not included in the assessment. There was some uncertainty by the acting manager on how to complete the new style assessment, which generates a number related to the needs of the service user. This number then equates to staffing numbers. The manager was not clear how the score is established and said she had limited guidance. A support worker is currently in the process of carrying out an assessment with, the acting manager believes, no training. No service user should be admitted to the home unless a suitably qualified person has carried out an assessment of their needs and aspirations, which Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 10 involves the service user and their representatives. A requirement was made to address this. There were no contracts between the home and service user in the service users files sampled. Each service user should have a contract detailing the terms and conditions of their stay including the fee, what is included and their roles and responsibilities. The manager agreed to address this. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 Personal goals are not reflected in support plans. Decision and choice making could be restricted due to a lack of communication support. Levels of participation in the day-to-day running of the home are low. EVIDENCE: Each service user has an individual service user plan or support plan. Individual records are now held separately in line with the Data Protection Act as required at the last inspection. Service users information is held securely and was organised. The support plans sampled lacked detail and information. Significant life events were not recorded. There was no reference to supporting a persons hopes and dreams. Some had been reviewed although others lacked effective review especially following a change, incident or accident. Some interventions needed by staff to support a persons needs were not detailed. Risk assessments are included in service user plans. Some risk assessments lacked detail and had not been reviewed following a change in need or accidents/incidents. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 12 There were no communication guidelines or interventions in any of the plans sampled even though the home supports service users with communication needs. There was evidence that families are involved in developing a person’s plan. The Inspector discussed service users plans at length with the acting manager. Both agreed that service users would benefit greatly if person centred approaches are implemented. The lack of effective and alternative individual communication systems means that service users opportunities to make choices and decisions could be restricted. Daily records do not demonstrate how individual choices and decisions have been made. This is compounded by the lack of detail in assessments and support plans. Each service user with a communication need should have a communication assessment carried out by a suitably qualified person to increase choice and decision-making. There are some environmental restrictions in place for example the kitchen and dining room are closed off to service users at times. The acting manager said ‘Service users are not allowed to go into the kitchen’ The home must review these environmental restrictions as they appear to have become institutionally accepted. Restrictions on choices, freedom and facilities must only be made in the best interests of service users. The Inspector observed breakfast time at Osborne Court on the second day of the inspection. Staff cooked the breakfast, served the breakfast to service users in the dining room and cleared the used crockery away. All meals are cooked in a central kitchen by staff and the waking night staff prepare vegetables. The atmosphere was relaxed and there was a choice although the ethos was to do things for service users rather than do things with. There is no shift plan in place therefore shifts are not planned around service users needs. This leads to service users ‘doing their own thing’ Staff said ‘M just likes to follow staff around’ The Inspector observed staff interactions with service users and recorded levels of engagement and participation. Levels of participation, staff interaction and engagement were low. This was discussed in detail with the team leader as an area for improvement. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14,15 There is a lack of opportunities for personal development on offer at the home. Service users feel there is a lack of suitable leisure activities on offer. Relationships with families are supported although service users may not get the support they needs with other relationships. EVIDENCE: Most of the service users attend a day centre on weekdays. Some service users remained at the home on the days of the inspection. Some service users and relatives said there was a lack of activities. The acting manager and staff agreed and said that staff shortages mean there is a lack of activities on offer. The Inspector observed missed opportunities to engage service users in everyday activities such as housework and daily living skills. As mentioned, staff were observed doing things for service users rather than doing things with service users. The home has some resources like a pool table and computer although staff are not deployed to facilitate any planned sessions. The team leader said that some spontaneous activities had proved popular although there is nothing structured or planned for example a shift plan. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 14 A more able service user took part in helping with the laundry although service users with more profound needs did not. Service users with more complex needs must be offered specialist interventions and opportunities by trained staff to participate in meaningful activities. The Inspector required that the acting manager consult with service users about their preferred activities. Activities should then be planned and facilitated accordingly to meet the service users needs and preferences. Providing more opportunities for activities will increase levels of engagement and participation. Service users must also be supported to take part in daily tasks like the laundry, preparing and cooking meals and housework. The Inspector discussed an incident report with the acting manager. It was clear that staff had given service users inappropriate advice. Staff actions may also have compromised service users confidentiality. Service users must be supported to develop and maintain personal relationships including intimate relationships with specialist guidance and advice sought where necessary. Staff must know when to seek professional advice and support. The manager agreed to address this. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Service users know their personal care needs will be met. Service users health needs are generally met although service users would benefit from a more detailed health action plan. Medication practices have improved. EVIDENCE: Basic personal care needs are recorded in service users plans. More detail will ensure that staff are aware of how a person prefers to be supported. One service user plan mentioned that a service user needs extra support with personal care although there was no intervention to meet this need. Staff said that some service users prefer certain staff to support them. This was not detailed in service users plans. The manager agreed that this could be improved. The home has supported service users to access health services. As with personal care needs service users basic health needs are recorded. Some specialist guidelines for example how to support a persons epilepsy were not in place. The Inspector recommended that the home introduce health action plans for all service users as part of the person centred planning process. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 16 The Inspector carried out an audit of medication practices. Two pharmacy inspections were carried out following medication errors. Medication practices have improved with most of the requirements now met. Guidelines for specialist techniques are now in place, which have been agreed by a G.P. There have been improvements in recording and administration. Service users must give their consent to medication and treatment. The acting manager agreed to address this. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Not all complaints are recorded and responded to. Some staff are trained to recognise signs of abuse. EVIDENCE: The Inspector was informed that a relative made a complaint to the home in November 2005 and was still awaiting a response. There was no record of this complaint or of any investigation or action. The Inspector made an immediate requirement that events surrounding an incident in November 2005 be fully investigated. The service user, complainant and Commission should be informed of the outcome. The acting manager said she has attended adult protection training and has experience of adult protection issues. The manager could say how she would deal with suspected abuse when asked. Staff can attend adult protection training and complete a unit about adult abuse during their induction. The Inspector was concerned that there was no record of this induction or training for most of the staff. The acting manager provided a record of training, which showed only 1 out of 27 staff have attended adult protection training. The manager agreed to look into this ad said this may just be the record for 2005. There was no information at the home at all in respect of 2 staff. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27 Generally the home is comfortable and safe. Service users lives would be enhanced with improvements to the décor. Not all bedrooms promote service users independence. Bathrooms are sufficient. EVIDENCE: The home is generally safe and well maintained with a maintenance man on site to address minor repairs. There is level access throughout the ground floor. Stairs access the first floor. Some areas of the home would benefit from improvement. The acting manager pointed out that some furniture is worn. The patio area accessed through patio doors from the lounge is overgrown with weeds and does not attractive or welcoming. There is a broken chair swing on the patio. Some of the skirting boards and other paintwork is chipped and worn. One of the bathroom taps is missing and leaking. The Inspector required that the acting manager carry out an audit of furniture and fittings and produce a development plan to improve the home. All bedrooms are for single occupancy and have wash hand basins. Some bedrooms do not have locks fitted. The Inspector recommended that all Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 19 bedrooms be fitted with suitable locks and service users offered a key. Toilets and bathrooms are sited close to service users rooms. Bathrooms have been adapted to maximise service users independence. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 Staffing numbers are sufficient but could be more effective. There was no information and recruitment checks at the home for some staff. Staff have opportunities for training and development. EVIDENCE: The acting manager said that a figure is generated from an assessment of a service users needs. This figure leads to a staffing level. The acting manager said she was unfamiliar with this system but has support from other managers who use this system. There was sufficient staff on duty on the two days of the inspection. The acting manager said that service users stays are booked well in advance so staffing could be planned around the needs of the service users. Staff deployment did not appear to be effective. Shift planning and staff deployment was discussed. The inspector recommended that the home introduce a shift panning system. Shifts that are planned around service users increase levels of participation and engagement. Training is offered to staff on a rolling programme by KCC. The acting manager said that training is planned around the needs of the service users. The induction for new staff is accredited to the Learning Disability Awards Framework although there was no record of any induction for some staff. Staff are supported to complete a National Vocational Qualification when they have completed their induction and probation. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 21 The Inspector sampled some staff files. There was no information at the home at all in respect of two members of staff. The acting manager went to the attached day centre to get one of the staff members files although this did not contain the required information. There was information missing from the other two files sampled. A requirement was made to address this. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 There has been some changes in management which has lead to a period of instability for service users and staff. Service users views do not underpin the review and development of the home. EVIDENCE: Since the previous registered manager of several years retired there has been an acting manager at the home then a permanent manager. Currently there is an acting manager who has been in post since 30/1/06. This has lead to a period of instability and change for staff. Staff said they now feel more stable as they know the acting manager who has worked at the home previously and has been seconded from a KCC day service. The acting manager has several years experience in working with people with a learning disability and is working towards the required requirement to meet the National Minimum Standards. After talking to the acting manager and staff the Inspector felt that some systems have been changed without enough consultation with staff as staff and the manager were not completely clear about some of the new systems. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 23 This must be addressed so that all staff are familiar with the systems and procedures in use to ensure the service is run in the best interests of service users. Currently yearly questionnaires are sent to service users and relatives about the service provided. The acting manager said the results are published in a newsletter and sent to service users and their families. There were no results to see as the manager said the paperwork was in a staff locker. The pro forma of the questionnaire was seen and is typed on A4 paper. This is not accessible to all service users and should be developed to meet service users needs. At present this is the only formal way service users can air their views. The acting manager said a team leader plans to hold residents meetings although none had been held since 24/08/05. The acting manager talked through some ideas about how to support service users to air their views. The home must ensure that service users views underpin the review and development of the home. Service users must have the opportunity to make their views known in a way that meets their needs. Monthly audits are carried out as required under Regulation 26. Standard 42 was not inspected in full however, the Inspector found that not all accidents are recorded and reported as they should be. One family have not been fully informed about an incident even though they had formally requested this at a review in December 2005. Some accidents reports conflicted with daily reports and other reports. The recording and reporting of accidents must improve. An immediate requirement was made that the acting manager investigates the circumstances surrounding an accident at the home on 24/11/05 and report back to the family and CSCI with the outcomes and actions. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 X X 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 2 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 3 X X X LIFESTYLES Standard No Score 11 2 12 X 13 X 14 2 15 2 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Osborne Court Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 X DS0000037715.V272157.R01.S.doc Version 5.0 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 YA2 Regulation 14 Requirement The registered person shall not provide accommodation to a service user unless a suitably qualified person has assessed the needs of the service user, including their aspirations. Service users plans must be in line with the National Minimum Standards and good practice guidance. Service user plans must be kept under review. Following specialist advice where necessary each individual with a communication need must have individual communication guidelines. Service users must be supported to participate in all aspects of the running of the home in line with the standard. The registered person must consult with service users about the programme of activities and provide preferred activities in relation to recreation, fitness and training. Risk assessments must contain more detailed information and DS0000037715.V272157.R01.S.doc Timescale for action 31/03/06 2. YA6 15 31/03/06 3. YA7 Schedule 3 (l) 31/05/06 4. YA8 12 31/05/06 5. YA14 16(n) 31/05/06 6. YA9 13(4) 31/03/06 Osborne Court Version 5.0 Page 26 7. YA15 8. 9. YA22 YA24 10. YA34 11. YA42 12. YA39 13. YA24 be kept under review especially following accidents and incidents. 16(m) & Staff must support service 18(a) users relationships and have the competency to seek specialist advice and support when necessary. 22 The registered person must ensure that any complaint is recorded and fully investigated. 23 The registered person must produce a development plan for the home regarding improvements needed to décor, the garden, furniture and fittings. 17,Schedule The registered person must 2 ensure that records required in relation to staff are available for inspection including details of recruitment checks on staff. 12,13,37 The registered person must ensure that all accidents and incidents are recorded and reported appropriately. 12(3) The registered person must ensure that service users views underpin all review and development by the home. 12,13 Environmental restrictions must be reviewed. 31/03/06 28/02/06 31/03/06 31/03/06 31/03/06 31/05/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA20 YA5 YA20 Good Practice Recommendations Service users consent should be sought and recorded regarding medication. All service users should be issued with a contract detailing the terms and conditions of their stay. The door to the clinical room is fitted with a British DS0000037715.V272157.R01.S.doc Version 5.0 Page 27 Osborne Court 4. 5. 6. 7. 8. YA37 YA6 YA19 YA14 YA26 Standard (BS) 5 lever lock The manager should be suitably qualified. Person centred approaches should be used in assessment and care planning processes. All service users should have a health action plan. A shift-planning model planned around service users should be implemented to increase levels of participation and engagement. All bedrooms should be fitted with locks and service users offered a key. Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Osborne Court DS0000037715.V272157.R01.S.doc Version 5.0 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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