Inspection on 03/05/06 for Osborne Court

This inspection was carried out on 3rd May 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 14 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 13/02/06

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 Sally Hall Unannounced Inspection 3rd May 2006 10:00 Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 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 Vacant Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 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. The fee range for this service is £689.80 for low dependency, £763.87 for medium dependency and £894 for high dependency service users per week. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key Inspection at Osborne Court took place on 3rd May 2006 between 10am and 3pm, the link inspector Sally Hall was accompanied by a second inspector Jo Griffiths. A second visit was made on the 16th May by Sally Hall alone. On the first day of the inspection the Inspectors agreed and explained the inspection process with the Registered Manager. Time was spent reading a sample of care plans, written policies and procedures and records kept within the home. Service Users and staff were spoken with and a tour of premises was undertaken. On the second day the inspector went to collect the Pre inspection questionnaire and evidence other documentation not seen on the first day. The inspector was aided by the shift leader since the registered manager was on leave. The focus of the inspection was to assess Osborne Court in accordance with the National Minimum Standards for Younger Adults. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The home was ask to complete a pre–inspection questionnaire, and to send out surveys to service users, friends/families and other professionals that are involved with the service users at the home, evidence from these documents is also included in this report. What the service does well: What has improved since the last inspection? The medication recording and administration has improved and training is ongoing. The manager has identified a new room to house the medication which will remain at a more ambient temperature. The manager has started to send in completed required Regulation 37 forms when a significant incident has occurred in the home, rather than using the accident forms as before. Service Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 6 users have been given a contract and the terms and conditions. The terms and conditions are in a format that makes them easy to understand. 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. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The service users are provided with a Service Users Guide and there is a Statement of Purpose available for any new service users to make an informed choice about where they live. The home does not have a robust assessment procedure in place to ensure that all new service users individual needs can be met. Therefore the home could have difficulty meeting the needs and aspirations of all the service users in its care. Service users can be confident that they will be supplied with completed contracts/terms and conditions of their stay. EVIDENCE: The Service Users Guide is now in pictorial format appropriate to the service users needs. Evidence was also seen of a Statement of Purpose which had been reviewed recently. In the service users files sampled there were a number of different assessment documents. They did not cover all the recommended areas as per the National Minimum Standards and they were not dated. Assessments need to cover the following areas; cultural, religious needs, education, occupation and should Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 9 identify the wishes and preferences of individual service users. Many of the files other than the newest seen did not contain a care management assessment. They did have Service Delivery Orders from the local authority but these did not provide the detail of the care required, rather they just ask for respite care. The files themselves were confusing as they contained a large amount of information which was no longer current and in some cases it was difficult to know which information was the most recent. The manager said she plans to devise her own assessment tool, which she will ensure covers the requirements of the National Minimum Standard. Most service users had a KCC contract on file. There was a statement stating terms and conditions, which was in a more suitable format for the service users. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Service users are not included in the care planning process and therefore cannot be confident that their care needs and personal goals are reflected in the plan. Service users are supported to make decisions about their lives. Service users need to be consulted and encouraged to participate in all aspects of life in the home. EVIDENCE: The service users’ personal files were sampled. These were found to include service users’ support plans. However, the plans concentrated on the personal care provision and any behavioural problems. The plans need more detail in relation to the staff action required to meet the identified need and cover the following areas; social, occupational and educational needs. There was no evidence seen that service users are involved in the development of their own Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 11 plans. Person centred planning focusing on the service users needs had not been used; this would be beneficial as many of the support plans were written last year. During conversations with staff and the manager it was apparent that some service users needs had changed but these changes were not reflected in the service users’ support plans. Information was seen displayed in the entrance hall on advocacy services. The home does not have service users meetings. Risk assessments were seen in service users files sampled for fire and manual handling. However other potential risks have not been assessed, although from reading service users assessments and support plans these are easy to identify. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The home needs to do more to ensure service users have the opportunity for personal development. Service users would benefit from more outings and need to be part of the local community and are aware of forth coming events in the town and locality. Family involvement is welcomed by the home, but is not actively encouraged as the service users here are on short term care to give carers a rest. The service users can be confident that their rights will be respected. The home offers a range of balanced meals in congenial surroundings in a family atmosphere. EVIDENCE: Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 13 In the files sampled the service users’ life skills were not fully explored with a documented programme to develop or enhance these skills. It is important to enable and encourage service users to develop life skills even if the service users ability may be limited. A shift leader spoken to went through some of the activities the service users are encouraged to participate in. Staff spoken to said service users do not want to participate in activities and are happy watching the television. Staff said they do facilitate activities such as playing pool, using the computer, (which is manly used for games) but there was no programme of activities available for the service users to choose from. It is recognised that as most service user staying at Osborne Court do so for short periods of respite care only but it is still important to give a choice of activities, which includes outings. Staff confirmed that the home does have a mini bus but that apart from taking service users to health appointments they are not used. The mini bus is a facility the home should be making full use of for the benefit of the service users. Staff explained that the problem is that all the staff qualified to drive the mini bus have left. The Service Users have unrestricted use of the garden during the warmer months of the year. There are benches out on a patio all year round that service users can access. The grounds are large and shared with the day facility attached to the home. Most of the service users attend this day centre. However the educational and social needs are not well addressed in the care plan. The grounds have a number of green houses, but these again are not used to there full potential because the person who organised this activity has left staff explained. The cook explained that knowing the likes and dislikes of the service users is invaluable in putting together a menu that has choice enough to suit all the service users tastes. The cook ensures much of the food is freshly prepare daily and this includes cakes and the main meals. Service users are offered at least one cooked meal daily. There is a range of snacks available that staff can access when the cook is not on duty. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Service users cannot be confident that they will receive personal support in the way they want it. The recording of service users’ physical and emotional health needs is inadequate. Service users can feel confident that they will receive their medication as prescribed. EVIDENCE: Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 15 The medication storage, recording and administration records were seen and sampled. As this is mainly a respite home, the service users’ families provide medication. All medication seen was in the original boxes and these were clearly labelled. One bottle of tablets however showed that the medication had been dispensed some time before and the shift leader was asked to check this in future. The eye ointment in use did not show the date that this was opened this was discussed with the shift leader. The shift leader was able to tell the inspector what he would do if a service user refuses medication, and where this would be recorded. The Medication Record Sheet has been designed for the short stay service users and contains most of the required information. However it did not record the service users doctor name. As the doctors are not always local it was recommended to also record the doctors telephone number on the record. The medication storage room is a very warm room and it has a fan in constant use to reduce the temperature, the manager explained that they do have plans to move the medication storage and the proposed room was seen and would be more suitable. The training records seen indicated that a number of staff have had medication training, however the home did report via the regulation 37 for an incident where medication was given to the wrong person. The Medication Record Sheets have been changed and the staff member is under go further training. In the service users’ files sampled some of the service users personal care needs were recorded on the support plan, these would benefit form more detail. Where a service user had lost a close family member the manager explained that the home had involved S.A.L.T. and arranged bereavement counselling, however there was no evidence of this seen in the records. In the daily log for a service user it recorded that a relative had requested that a haemorrhoid cream be applied, this is an invasive procedure and it was not a prescribed medication. This should be detailed and agreed in the care plan. No nutritional assessment was seen for service users, particularly in the case of one individual who is having eating problems, there was also no records seen that the service users is being weighed. The wishes of the service users in respect of death are not recorded because this is a respite home. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. The home has a complaints policy and procedure however staff need to be trained on how and where to record those complaints. The home has a robust adult protection protocol in place, however staff have not all had the required training. EVIDENCE: The Home has a complaints procedure and policy in place, which contains time scales, and what to do if the complainant is not happy with outcome of a complaint made. This is available in a suitable format for the service users that stay at the home. The senior staff on duty however were not aware how and where a complaint should be recorded. The manager confirmed that there had been no complaints since the last inspection. Service users surveyed commented that they did not all know what to do if they wanted to complain. The home follows the adult Protection procedure provided by the local authority. During the last inspection it was identified that a large number of staff were in need of adult protection training. Evidence was seen that a request has been made to the training department to provide this training. Given the importance of this training it is highly recommended that all staff should have completed the course in the next six months. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Service users benefit from being able to chose the room they will spend their short stay in. The home is comfortable, clean and generally well maintained. Whilst some service users stay is only made possible because of the specialised equipment the home provides, this could be improved if a call system could be introduced for the more dependent service users. EVIDENCE: The home is on two floors, the upper floor can be accessed by two separate staircases. There is no lift available therefore service users who have a physical disability can only reside in the ground floor rooms. The home appeared generally well maintained, although some areas are now showing wear and tear. The home employs domestic staff and a maintenance man. The home was very clean and bright on the day of the inspection and the communal living areas had a homely feel. The lounges are large and comfortable and there is a separate activity room with a pool table and a separate sensory room and smoking room. Furniture was seen to be of good quality and domestic in nature. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 18 Service users all have their own rooms but these do appear a little sparse. Because service users are only at the home for a short time they do not have the opportunity to personalise their individual rooms. Service users spoken to said that they like the room they had chosen and that they do get to choose the room they want. All bedrooms have a wash hand basin and service users are able to have a key and lock their bedrooms during their stay. The home does not have a call alarm system for service users to summon help when they are in their bedrooms. The shift leader spoken to about this confirmed that service users who are not mobile are connected with staff at night by a baby type monitor. They also have the use of walkie-talkies that can be used by both service users and staff should the need arise. The staff member said that if there was an emergency at night they can contact the sleep in member of staff via the bell out side their room or if this does not wake them then they have a key and they can go in and wake them. The home is advised to look at these arrangements and seriously consider a call alarm system to ensure that service users can summon help at any time they are in their bedrooms. A baby monitor is not appropriate if it is carried around with the staff member, nor is it if the staff member is not in earshot. The home also has a self-contained flat where Service users have the opportunity to live more independently and develop their daily living skills. The gardens are large and accessible from one of the lounges via patio doors as well as other exits. There is an attractive patio area and greenhouses. There are facilities provided for staff. The home employs domestic staff The laundry facilities are of a good standard, and staff said that they have access to PPE when it was needed. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 19 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): Quality in this outcome area is adequate. Service users benefit from a staff team that is sufficient in numbers and is regularly supervised. The care of service users may be compromised by the lack of training offered to staff. EVIDENCE: Shift leaders take turns to sleep in with one waking staff on duty. The shift leaders training records were seen and those sampled had attained an NVQ level 3 in care plus a wide range of other associated training. Several members of staff were spoken to during the inspection process and had all worked at the home for many years. The Manager said that the present rotas are becoming more flexible now that one full time staff who has left has been replaced with 2 part time staff. This has enabled the home to have more staff in the home when it has really been needed for shorter periods of time. The manager said that she does increase the staffing level to meet the needs of the service users at any given time. A number of staff files were sampled. The files still did not contain all the documentation required. The manager said that a lot of the information is held Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 20 centrally. The manager has been asked to ensure that there are copies of all the relevant information required under the regulation in the file in the home. The manager had compiled a list of all the staff training to date for each individual member of staff. It was apparent that many of the staff have not done all of the required training. The manager did show documents where she has requested training from the training department. This was mostly for adult protection training, which was identified during the last inspection. However it was recommended that the manager devise a way of identifying which courses staff are still required to attend and ensure that training that needs to be refreshed at set intervals is programmed in. When sampling the staff files, it became apparent that some staff who the manager had recorded as having an NVQ did not have a certificate on file and no organisation had been identified on these as the awarding body. All certificates need to be copied signed to say the original has been seen and held on the staff members file. The manager was asked to arrange for staff to bring in missing training certificates so qualifications can be checked. If all the NVQ’s seen recorded are valid then the home has a achieved having 50 of it staff trained as per the National Minimum Standard. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 21 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): Quality in this outcome area is adequate. The service users benefit form a well run home, however this is being put at risk now the manager’s position has been put on hold. Whilst the service users views were not being adequately sought work on a new questionnaire format should address this. The service users best interests are safeguarded by the policies and procedures with in the home. Whilst the health and safety of service users is promoted, the risk assessment, reporting and documenting procedures need to improve. EVIDENCE: The current acting manager who has been in post since 30/1/06, she explained that although the post had been advertised interviews are on hold until December 06. The staff have already endured a period of instability and change and this further delay is not acceptable. The Commission for Social Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 22 Care Inspection would want to see an application to register a new manager in the next 3 months as the home has been operating with out a registered manager for over a year. When discussing quality assurance with the manager she explained that new questionnaires are being designed the new format will make it easier for participants and covers more. Currently questionnaires have been sent to service users and relatives about the service provided yearly. The acting manager said the results are published in a newsletter and sent to service users and their families. At present this is the only formal way service users can air their views. The acting manager said that they do not have residents’ meetings. The acting manager had given some thought to how to support service users to air their views, other than the questionnaire, it is important that this be implemented. The home’s accidents are recorded and reported and the Commission for Social Care Inspection have received a large number of these. This was discussed with the manager it is not necessary to send these. It is however necessary to inform the Commission for Social Care Inspection of incidents that affect the service users, matters of health and safety etc. The manager was shown where to find the list of things that have to be report under Regulation 37. The manager was asked to ensure that the form for notifying incidents on is fully completed, and that follow up information is also sent. The Pre-inspection questionnaire was collected from the home and confirmed that all the maintenance certificates are up to date. The COSHH file was seen and recent amendments were evidenced. The fire log was available and fire signs were seen around the building. The home had a number of generic risk assessments in place for the building, there was no room by room assessment seen, it is strongly advised that completed urgently. The home’s policies and procedures were seen and those sampled had been reviewed annually. Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 23 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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 3 LIFESTYLES Standard No Score 11 2 12 N/A 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 2 2 3 2 3 3 2 x Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 24 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, and this has been recorded in a way that all the relevant information is included Service users plans must be in line with the National Minimum Standards and good practice guidance. Service users should be part of the process. 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. Timescale for action 30/07/06 2. YA6 15 30/07/06 3. YA7 Schedule 3 (l) 30/06/06 4. YA8 12 30/06/06 Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 25 5. YA14 16(n) The registered person must consult with service users and produce a programme of activities. providing preferred activities in relation to recreation, fitness and training. Risk assessments must contain more detailed information and be kept under review especially following accidents and incidents. The registered person must produce a development plan for the home regarding improvements needed to décor, with particular attention on the bathrooms. 30/06/06 6. YA9 13(4) 30/06/06 7. YA24 23 30/08/06 8. YA34 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 continue to ensure that all accidents and incidents are recorded and reported appropriately. Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. The home needs to have a permanent registered manager to ensure continuity and a stable work place for staff and service users. Staff have the competencies and qualities required to meet service users’ needs, by ensuring that all staff training needs are met 30/06/06 9. YA42 30/06/06 10. YA11 16,2M 30/06/06 11. YA37 8, 9 01/09/06 12 YA32 18 31/12/06 Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 26 13 YA23 13 14. YA39 12(3) The registered person ensures 31/08/06 that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy by ensuring that all staff have adult protection training The registered person must 30/06/06 ensure that service users views underpin all review and development by the home. 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. Refer to Standard YA37 YA14 Good Practice Recommendations The manager should be suitably qualified. A shift-planning model planned around service users should be implemented to increase levels of participation and engagement. Ensure staff are aware that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and staff know what to do if a complaint is made. Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 YA22 4. YA13 Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Osborne Court DS0000037715.V292487.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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