Inspection on 05/02/07 for St Anne`s

This inspection was carried out on 5th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Anne`s 29/06/07

St Anne`s 09/02/06

St Anne`s 02/08/05

St Anne`s 25/11/04

St Anne`s 23/07/04

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Thorndene

Insight - Eastchurch

Southfields

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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 St Anne`s 4 St Anne`s Road Eastbourne East Sussex BN21 2DJ Lead Inspector Nigel Thompson Key Unannounced Inspection 5th February 2007 09:30 St Anne`s DS0000021436.V328897.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 St Anne`s DS0000021436.V328897.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. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Address 4 St Anne`s Road Eastbourne East Sussex BN21 2DJ 01323 728349 01323 728349 stanne4christine@aol.com 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) The Complete Care Group Mrs Christine Ann Klassen Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of people accommodated must not exceed six (6). Only adults with Autism and/or Asperger’s Syndrome to be admitted. Date of last inspection 9th February 2006 Brief Description of the Service: St Annes is overseen by its parent company, The Complete Care Group, and is registered to provide care for six adults with Autistic Spectrum Disorders (ASD). St Annes is a large detached Victorian house within walking distance of Eastbourne town centre and railway station. Service users individual and collective social care needs are assessed and met. Community participation is promoted and service users are enabled and supported to access local amenities, including the cinema, college, theatre, swimming pool and restaurants. Activities within the home include aromatherapy, computer skills, board games, karaoke and cooking. The dedicated staff team provide structured, yet flexible opportunity programmes to enable service users to develop social, emotional and independent living skills. There is spacious living accommodation with six bedrooms that have shower en-suite facilities. Adequate communal areas are provided to meet the individual and collective needs of the service users, including a sensory room and a light and spacious lounge at the front of the house. There is a dining room and kitchen to the rear of the home and a conservatory that leads into a large rear garden. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees at St Anne’s, as of 5 February 2007, is £1513.8 £1943.00 per week. Additional charges are made for hairdressing, holidays, toiletries and magazines. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours in February 2007. It found that the majority of the key National Minimum Standards that were assessed had been met with one standard partially met. The overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were five service users living at the home. The inspection involved a tour of the premises, observation of working practices, examination of the home’s records and discussion with four service users, three members of staff, the Registered Manager, Deputy Manager and Registered Provider. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. The purpose of this inspection was to monitor care practices at St Anne’s and the focus was on the quality of life for people who live at the home. What the service does well: An experienced and committed management structure and dedicated support staff continue to work hard developing and maintaining the evidently stimulating, open and inclusive atmosphere within the home. Thorough policies and procedures are in place for the admission and ongoing care and support of service users. Effective communication and consultation systems enable service users to be directly involved in developing and reviewing their individual care plans as well as many decision making processes within the home. Staff have formed close working relationships with service users and have awareness and understanding of their care and support needs. Staff receive effective induction and foundation training, formal supervision – regular and structured one-to-one meetings with individual care staff and their manager – and are valued and supported by the management team. St Anne`s DS0000021436.V328897.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. St Anne`s DS0000021436.V328897.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 St Anne`s DS0000021436.V328897.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The thorough admission policy and procedures ensure that service users are admitted only on the basis of a full needs assessment, undertaken by people competent to do so. Prospective service users know that the home is able to meet their individual care and support needs. EVIDENCE: Information available to prospective and existing service users including the Statement of Purpose and Service User Guide have been thoughtfully and imaginatively produced and are both comprehensive and informative. Following discussion with the manager, however, it is recommended that each document be reviewed and updated to reflect the recent managerial changes, including the appointment of a Head of Care. A comprehensive brochure is in the process of being developed and was described by the provider as being ‘Work in progress’. As part of the home’s admission policy and procedure, a detailed preadmission assessment form has been developed and includes information relating to the individual’s personal, medical, social and psychological care and St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 9 support needs. It was noted that the assessment also includes details of the service user’s autistic spectrum disorder, their communication, leisure interests and emotional wellbeing. Prospective service users and their relatives are encouraged to visit the home and have the opportunity to look around and meet with members of staff and existing residents. Having moved into the home, the manager confirmed that service users undergo a six week trial period, during which time their suitability and compatibility with existing service users are assessed and it is established whether their identified care and support needs are able to be met. A review of the placement is held after this time to establish their suitability and compatibility and decide whether or not their needs can be met within the home. Subsequent placement reviews are held on a six monthly basis and routinely involve the service user, a relative or representative where appropriate, the Care Manager and staff, including the individual’s key-worker, from St Anne’s. Since the previous inspection there has been one service user admitted to St Anne’s. Relevant documentation relating to the recent admission to the home was inspected and found to be comprehensive, up to date and well maintained. Review reports that were examined were found to be full and comprehensive with updated details of the service user’s physical and emotional wellbeing, their social interaction and levels of communication and community participation. It was noted that these reports also include a detailed overview of the agreed goals and objectives. St Anne`s DS0000021436.V328897.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, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans enable staff to meet the assessed support needs of service users in a structured and consistent manner. Systems for consultation and participation are effective. Service users are treated with respect and encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Satisfactory care plans have been developed for each service user, clearly linked to the individual’s assessed needs. The plan is formulated by the keyworker, manager and evidently with the direct involvement of the service user or family member, as appropriate. Staff spoken to during the inspection confirmed that, despite the variable communication of some service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 11 The manager confirmed that service users’ care plans are formally reviewed annually to ensure that the individual’s care and support needs continue to be met in a structured and consistent manner. The individual care plan and other relevant documentation relating to the new service user was examined and found to be up to date and generally well maintained, with evidence of regular reviews having taken place, reflecting changing needs and circumstances. However, in other care plans that were examined, there was little evidence of recent reviews having been carried out, (most recently updated in May 2006) particularly in respect of guidelines for staff and service users’ personal risk assessments. There was also still little evidence of service user involvement in this process. These issues were highlighted and a requirement and recommendation made following the last inspection. However, there is insufficient evidence that the matter has been satisfactorily addressed and consequently the requirement remains outstanding. As previously documented, a comprehensive ‘Weekly Evaluation’ sheet is completed by key-workers in consultation with individual service users. The regular discussions and structured recording format continues to provide an effective system of monitoring changes in emotional and personal support needs and demonstrate good practice. The manager confirmed that service users continue to be consulted regarding many aspects of their day-to-day living, including menu planning, recreational and leisure activities and holidays. St Anne`s DS0000021436.V328897.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. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs, preferences and abilities. It was evident from direct observation and through discussions with members of staff that the comprehensive ‘Opportunity Plans’, in place for each service user, continue to provide a structured programme of daily activities, reflecting individual interests and preferences. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 13 Opportunity plans that were examined included activities as diverse as: ‘music’; ‘sensory room’; ‘videos’; ‘karaoke’; ‘walk in the park’ and ‘free time’. Community participation has always been a focus for the home and the manager confirmed that as part of individual opportunity programmes it is becoming a more significant part of the lives of many service users. Three service users continue to attend the local college, where courses in which they have chosen to partake include cookery and pottery. The manager confirmed that service users’ family links continue to be supported, where appropriate, with variable contact with relatives being maintained in the majority of cases. A four-week rolling menu is in place, providing service users with a balanced, varied and nutritious diet, which reflects individual choice and preference. An alternative to the main meal is always available. The menu has been made accessible to all service users by the effective use of symbols and pictures. The manager confirmed that staff and service users routinely sit together for the evening meal. Service users’ weight and dietary needs are monitored regularly and menus and any dietary needs and changes are discussed during regular staff and service users’ meetings. St Anne`s DS0000021436.V328897.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. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: In accordance with their personal care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, service users were observed being supported in a sensitive, professional and respectful manner by members of staff. Documentary evidence was in place to demonstrate that the health and emotional care needs of service users continue to be met within the home. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 15 required. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Up to date and detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. Medicines are stored and recorded appropriately. The manager confirmed that all staff who have responsibility for administering medication have received appropriate training and are individually assessed and authorised to do so. This was confirmed through discussions with staff and supported by training records examined. St Anne`s DS0000021436.V328897.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. The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. Service users are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: Close working relationships, effective and ongoing communication and consultation with service users provide adequate opportunity for any concerns to be raised and discussed, before they become complaints. Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or making a complaint if necessary and each person was confident that they would be listened to. The organisation has produced detailed policies and procedures relating to adult protection and abuse, including a whistle blowing policy. The manager confirmed that staff have undertaken specific adult protection training, in accordance with the multi agency guidelines for the protection of vulnerable adults. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 17 This was supported through discussions with members of staff during the inspection and evidenced through individual training records. St Anne`s DS0000021436.V328897.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, 26, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is accessible, safe and clean and remains suitable for it’s stated purpose. Service users benefit from accommodation that is comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: It is evident that there has been some improvement in the physical environment of the home since the previous inspection and standards were found to be generally satisfactory throughout. Of note was the redecoration of some service users’ rooms and refurbishment of several communal areas including the sensory room, kitchen, bathroom and dining room, which has also had new curtains fitted and replacement chairs and settees. Replacement furniture has also been provided in the conservatory. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 19 During my ‘guided tour’ of the premises, including service user accommodation and spacious communal areas, it was evident that the well maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant environment for the service users. Where appropriate they have been modified so as to take into account the autistic characteristics of the service users. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ individual rooms, which clearly reflects individual tastes and interests. On the day of the inspection, levels of cleanliness and hygiene throughout the home were found to be generally satisfactory. St Anne`s DS0000021436.V328897.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 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is always sufficient trained and competent staff on duty to meet the assessed needs of the service users. Service users are protected by satisfactory staff recruitment policies, procedures and documentation. EVIDENCE: In addition to the comprehensive induction programme undertaken by all newly appointed staff, the manager confirmed that appropriate core skills training is provided, including first aid, food hygiene and fire safety. This was confirmed through discussions with staff and supported by individual training records examined. The manger confirmed that there are currently five members of care staff who hold the National Vocational Qualification (NVQ) level 2, or above. A further four members of staff are presently studying for the award. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 21 A current duty rota was made available for inspection. However, as discussed, it is recommended that the designation of staff on duty at any time be recorded. To address the unpredictable and frequently stressful nature of working at St Anne’s, the manager and deputy manager continue to personally provide all care support staff with formal supervision every month. The management team evidently operates an ‘open door’ policy, with staff able to discuss any issues at anytime. This was evidenced by supervision records examined and through discussions with staff, spoken with during the inspection, who acknowledged the benefits of effective supervision and confirmed feeling valued and supported by the manager and deputy manager: ‘They are both so supportive and always have time for you’. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. The manager confirmed that the home is currently looking to recruit another support worker to replace a member of staff recently promoted to a senior. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a competent and experienced management team and are protected by satisfactory health and safety procedures. Their best interests are safeguarded by adequate and effective quality monitoring systems. EVIDENCE: The dedicated and experienced Registered Manager and Deputy Manager continue to work hard to maintain a safe, supportive and stimulating environment within the home. Since the previous inspection the Manager has successfully completed the Registered Manager’s Award (RMA) and the Deputy Manager is hoping to complete later this year. St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 23 Staff and service users, spoken with during the inspection, confirmed how approachable and supportive the Manager and the Deputy Manager are: ‘They are top people, very supportive and helpful and certainly the best managers I’ve had’. As previously documented, since the last inspection, a Head of Care has been appointed, who will have responsibility for overseeing the running of St Anne’s and who will be the line manager for the current Registered Manager. The home continues to operate effective quality monitoring systems, including six monthly satisfaction questionnaires for both service users and their relatives. Collated responses from the most recent survey indicate a high level of satisfaction with the home and the care and support provided: ‘……is very happy at St Anne’s. It gives me peace of mind to know that she is being looked after so very well’. ‘I consider St Anne’s is a very good environment and staff have a genuine concern for people’s development and welfare’. The manager confirmed that the health, safety and welfare of service users and staff remains of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded and fire safety systems within the home, including alarms and emergency lighting are tested on a regular basis. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. St Anne`s DS0000021436.V328897.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 X 5 X 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 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 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 3 3 3 X X 3 X St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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(2) Requirement It is required that the service users individual care plan, including staff guidance and risk assessments, be regularly reviewed, to reflect any changing needs or circumstances. (Previous timescale of 30.04.06 not met). Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations It is recommended that information made available to existing and prospective service users, including the Statement of Purpose, Service user Guide and brochure, be kept under review to ensure it accurately reflects the current situation within the home. It is recommended that risk assessments and guidance notes for staff, contained in service users’ individual care plans, be signed and dated to indicate when they are reviewed and by whom. DS0000021436.V328897.R01.S.doc Version 5.2 Page 26 2. YA6 St Anne`s Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent 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 St Anne`s DS0000021436.V328897.R01.S.doc Version 5.2 Page 27 - 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!