Inspection on 14/07/09 for Sansigra

This is the latest available inspection report for this service, carried out on 14th July 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sansigra 10/03/08

Sansigra 19/03/07

Sansigra 24/10/05

Sansigra 20/04/05

Sansigra 06/12/04

Sansigra 19/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Sansigra High Road Zelah Truro Cornwall TR4 9HN Lead Inspector Alan Pitts Key Unannounced Inspection 14th July 2009 09:00 Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sansigra Address High Road Zelah Truro Cornwall TR4 9HN 01872 540363 01872 540363 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) Mrs Ann Penellum Mr Alan Graham Penellum Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include one named person outside of the normal age range of the Home. Total number of service users not to exceed a maximum of 8 Date of last inspection 14th August 2008 Brief Description of the Service: Sansigra is situated in the village of Zelah with easy access off the main dual carriageway to Truro or Penzance. The village has suitable facilities such as a public house. The home has parking, and spacious and pleasant gardens. The property is a large house that has been extended to accommodate up to eight service users, with the owners also living in the home. The home is well maintained and suitably furnished. Each bedroom in the home is single occupancy with a hand basin provided. Three bedrooms are available on the ground floor, with a walk in shower facility also available on this level. The ground floor is accessible to wheelchair users. Weekly fees range from £293 to £346. There are no additional charges to service users for petrol when the homes transport is used for outings or appointments in the community. There are additional charges for alcoholic beverages, hairdressing, confectionary, private chiropody, dry cleaning and offsite entertainment. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Two inspectors carried out this inspection over a period of approximately eight hours. We spoke with one resident, the registered manager and her husband, and a member of staff. We looked round the home including the rooms of some of the people that live there. We inspected the homes’ documentation. We also took into account information provided by surveys sent to the people that use the service and staff. Overall, the home has continued to make marked improvements since the last two inspections and can demonstrate individualised care and a good quality of life for the people that live there. There is still room for improvement, as suggested by the recommendations in this report, but the owners are to be commended for their efforts to improve the quality of care offered. What the service does well: The residents have ready access to health care professionals. The people that live there enjoy varied and individual activities. The environment is maintained to a good standard. There have been no complaints since the last inspection, and the registered providers have shown that they respond positively to external input and viewpoints. The provider ensures that Criminal Records Bureau (CRB) checks are sought and references taken up for all staff. The home adheres to a robust recruitment procedure. Records are generally informative, with the exception of specific points raised in this report. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Sansigra DS0000009166.V376459.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 Sansigra DS0000009166.V376459.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 2, 4. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have not been any new admissions since 2006. Residents and their representatives are given the information they need to make an informed choice regarding their care provider. The provider is fully aware of the requirement for a proper pre-admission assessment. EVIDENCE: The Statement of Purpose (SOP) and Service User Guide (SUG) documents have been reviewed since the last inspection to ensure they include accurate information about staffing, and the day-to-day role of the owners. The SUG is available in large print, and both documents are available to the people that live there on the ‘information table’ in the lounge. We discussed the benefits to people with sensory deficits of having the document(s) available in alternative formats (e.g. video/audio). The home has accommodated the same residents for a long time. There have been no new admissions since the last inspection. There is assessment and review information on their personal files to show that their needs are being monitored and reviewed. Comments received confirm that prospective residents are given the opportunity to visit and/or stay. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 6, 7, 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence of residents making informed decisions and taking responsible risks. The home is run in the best interests of residents, who are involved to the best of their capabilities in decision-making and selfdetermination. EVIDENCE: We looked at 3 of the care plans and their related documentation. The home is now using a new tool for their assessment and care needs documentation. The care plan itself is written in large type and is easy to understand. Whilst informative about many aspects of the individuals’ life, including personal preferences, more detail would benefit where assistance is necessary and where, for example, an individual chooses not to use equipment available. Avoid phrases such as “needs assistance”, rather say what is meant. Documentation demonstrates well choices made on a daily basis. There is clear Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 10 evidence of frequent and regular review of care plans, including the residents’ signature where possible. Our discussions and the care plans showed the considerable efforts made by the registered providers and staff to secure activities that have been specifically requested by residents. Risk-assessments are much improved and identify risk and a statement of the action to take to minimise any risk. More should be done to ensure all aspects of life are included (including interaction with livestock). We know from our discussions that care is taken to minimise risks, but these steps should be documented. There is evidence of residents making decisions in a meaningful way in the daily records and these are much improved, providing a greater level of detail. They are written in the first-person and signed by the resident. The entries in one file were also noted to reflect the manner of speech of the resident. The people that live there are involved in preparing meals and packed lunches for the next days’ activities. The registered providers have used quality assurance questionnaires to ascertain the views of others about their service. Relevant information is available to the people that live there. All of the residents have someone (e.g. family member) outside of the home acting in their interests. The people that live there have their own bank accounts. Individuals’ monies are paid directly into their own accounts. There are financial records for each resident. The individual resident receives his bank statements, and Mr Penellum goes through this and the home’s records with the resident. The home’s records are supported by receipts. The home makes no charge for transport to activities, though some activities attended do make a charge for their transport. As discussed at the time of the inspection, consideration should be given to the secure storage of information and records to ensure confidentiality and security. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 11 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): This is what people staying in this care home experience: NMS 12, 13, 14, 15, 16, 17. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A range of social and recreational opportunity is provided in keeping with known preferences and capabilities. Residents engage with the local community, and all have appropriate contact with people important to them. Residents’ rights and capacity as adults is recognised. A balanced diet is provided. EVIDENCE: The immediate community is used, and some local residents take advantage of the eggs produced by the home’s chickens. Residents also make use of the local farm shop and the pub. There is evidence of a wider range of activities being undertaken, and residents benefiting from these. There is good evidence of activities being arranged for individuals, and small groups, and alternatives Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 12 being provided for those not wishing to participate. There is a visitors’ book, which shows social and professional visitors. There are still minimal numbers of social visitors, but the registered providers and care notes evidence the efforts being made to assist individuals to meet with peers both outside the home and at home. Four residents access college facilities, and all access external activities of some description. The home has a variety of livestock (chickens, horses, cows) and the people that live there have varied involvement in their wellbeing and maintenance. Residents are asked what they would like to do in the evenings (weather dependent). Activities include games in the park, craft evenings, visits to the pub, cafes, and clubs. On the day of the inspection it was planned that 3 people would be staying at home, 2 assisting with the shopping, and 2 attending a local club. The people that live there keep their own photo diary of their life and activities (one is a speaking diary). Staff comments confirmed that activities are chosen by the people that live there There is evidence that the residents were asked if they wished to have a key to their bedrooms, and secure storage is available to them. There is evidence of meaningful choices being made by the residents, when at home. Records show flexibility in waking and bed times. New Freeview equipment was being fitted at the time of the inspection for all the residents to ensure continued viewing following the digital TV switchover. Photo cards are used to assist some residents in making decisions and to help them understand the options available to them. These cards are used and available for ‘everyday life’, activities, and food options. There is a weekly menu, and Mrs Penellum asks the residents every week what they would like the following week. There is information on special diets. Likes and dislikes for each resident are recorded. The menu choices are available as photographs of the meals to help residents choose. There is a record of the choices made and the food actually provided. A dietician has been consulted to ensure the menu provides a balanced nutritional diet. The residents also have information on healthy eating, provided by a visiting professional. The residents may have a meal whilst out at placements or on activities, and the registered providers take this into account when planning the days meal. There is evidence in the daily records of residents helping to prepare their own food, where appropriate. The people that live there have free access to the kitchen and the food and drink available there. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 18, 19, 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The personal and health care needs of residents are met with evidence of promoting privacy, dignity and good multi-disciplinary working taking place. EVIDENCE: Residents are aware that they have a choice whether they wish to go to a planned activity (e.g. day centre). Care documentation reflects residents’ preferences and individual needs in respect of their capabilities and assistance needed. People are provided with the technical aids and equipment necessary, though care should be taken to record if they choose not to use it. The registered providers have consulted with other agencies and professionals to ensure appropriate care is provided. There is clear evidence that the residents have ready access to health professionals, and assistance with attending appointments. All the residents have had an annual health check, and all receive dental, hearing, and optician checks. Additional referrals are made as needed. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 14 None of the residents self-medicate. There is only a small number of medicines on the property. The home is using domestic bathroom cabinets for the storage of medicines. There is a record of medicines received and returned. Medicine Administration Records (MAR) were seen to be in order. There is a relevant and appropriate medicines procedure. The registered provider uses a definitive list from the relevant GP(s) regarding the administration of nonprescribed homely remedies such as paracetamol, linctus, etc. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 22, 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were seen to interact with staff in a relaxed manner. The registered providers and staff have a clear understanding of Adult Protection issues and procedures that will protect service users from abuse. EVIDENCE: There is an appropriate complaints policy and procedure displayed in the residents’ lounge. The complaints procedure is provided to residents in pictorial format, suited to their individual needs. A complaints log is available – no complaints have been recorded. The Care Quality Commission has not received any complaints since the last inspection. The registered providers and all but one member of staff have attended adult protection training. The owners are aware of the local safeguarding procedures. All the staff are provided with a copy of the ‘No To Abuse’ booklet. Residents are protected by the home’s adherence to a robust recruitment procedure. The people that live there have regular contact with and access to people important to them, and other agencies outside of the home. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 24, 25, 26, 27, 28, 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The quality of furnishings and fittings is good and residents live in a safe, clean, and homely environment. EVIDENCE: Sansigra is a detached house in the village of Zelah. It is an impressive property set in its own grounds and well situated for Truro. It is well decorated and there is comfortable furniture and fittings provided. There have been no changes to the environment since the last inspection. Bedrooms contain personal belongings and are lockable (though the people that live there have declined keys). The accommodation suits the care needs and capabilities of the people that live there. The home was clean and tidy throughout at the time of the unannounced inspection. There are written guidelines in place to ensure good hygiene is Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 17 maintained and suitable arrangements in place for soiled laundry to protect staff and residents from cross-infection. Suitable facilities are in place to ensure good hand hygiene. Shower trays and baths were clean. A recent comment recorded after inspection from an Environmental Health Officer was “excellent standard of hygiene throughout the home”. The registered providers employ an external company to monitor their hot water and cold water systems. The laundry is small, domestic in nature, but functional. Sheets are laundered by an external contractor. The kitchen is domestic in nature, and was seen to be clean and orderly. As discussed at the time of the inspection, the registered providers should consider the potential implications of the current smoking legislation in relation to residents’ access through areas where the registered providers smoke. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 32, 33, 34, 35, 36. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is providing sufficient, competent support staff to provide for the welfare of the people that live at Sansigra. EVIDENCE: There is an ‘at a glance’ record of all staff training, supported by individual certificates of achievement and attendance. Mrs Penellum has achieved NVQ Level 5 in management and the Registered Managers Award. Mr Penellum has NVQ Level 4 in management. One staff member has NVQ Level 2 in care, and another is retired nurse. Mr Penellum has recently undertaken Deprivation of Liberties training. Staff meetings take place regularly and are recorded. Mrs Penellum confirmed that further training is planned throughout 2009. There is a duty rota, and this now includes the registered providers. The rota shows that the registered providers do have time/days off. A new member of staff was employed after the last inspection, and has undertaken a National Training Organisation compliant induction programme. The care documentation Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 19 inspected indicates that the residents need one carer to input with personal care, and the duty rota and registered providers confirm that there is always a minimum of 2 and usually 3 staff on duty during the day and evenings. Staff numbers reflect the changing needs of the residents or the planned activity. The registered providers live on site and provide ‘sleep-in’ cover for night care needs. The people that live there generally do not have any night care needs. The personnel file for the most recently appointed staff member was inspected and this showed that the home adheres to a robust recruitment procedure to protect residents. Staff are properly and regularly supervised, and this is recorded There are General Social Care Council Handbooks, and Sansigra Staff Handbooks available and provided to all new staff. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 37, 38, 39, 40, 42. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by qualified, competent managment. EVIDENCE: The registered providers are in day-to-day control of the home. There is no registered manager. The registered providers are experienced and Mrs Penellum is appropriately trained having achieved the Registered Managers Award. Records, discussion with the registered providers, and comments received from people that use the service and staff confirm that the home is run for the benefit of the people that live there. The registered providers have again made significant improvements since the last inspection, and this Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 21 continued improvement and commitment to self-determination by the people that live there is reflected in the overall outcome score of this report. Returns from last years’ annual quality assurance questionnaire, which they send to family and relevant professionals were seen. A summary of the findings has been included in the home’s Service User Guide. The home’s policies and procedures appear comprehensive and those seen were regularly reviewed. There are appropriate fire safety system maintenance contracts in place. There is evidence of regular maintenance and checking of other systems (gas safety certificate, electrical wiring). Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 22 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 X 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 3 28 2 29 X 30 4 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 3 3 3 3 2 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 3 X 3 X Version 5.2 Page 23 Sansigra DS0000009166.V376459.R01.S.doc NO 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. Standard Regulation Requirement Timescale for action 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 YA1 YA6 Good Practice Recommendations The registered provider should consider the benefits to people with sensory deficits of having the SOP and SUG available in alternative formats (e.g. video/audio). The registered provider should review the care plans to ensure they provide sufficient detail as to how identified goals are to be met (instead of “needs support”, say what exactly). The registered provider should review the riskassessments covering activities (including livestock). Consideration should be given to the secure storage of information and records to ensure confidentiality and security. The registered providers should ensure medicines are kept locked away and consider alternative means of secure storage. As discussed at the time of the inspection, the registered providers should consider the potential implications of the current smoking legislation in relation to residents’ access DS0000009166.V376459.R01.S.doc Version 5.2 Page 24 3. 4. 5. 6. YA9 YA10 YA20 YA28 Sansigra through areas where the registered providers smoke. Sansigra DS0000009166.V376459.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.southwest@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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