Inspection on 14/04/08 for 38 Sandgate

This inspection was carried out on 14th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

38 Sandgate 30/04/09

38 Sandgate 09/08/07

38 Sandgate 09/08/06

38 Sandgate 09/03/06

38 Sandgate 11/12/05

38 Sandgate 14/02/05

38 Sandgate 05/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 38 Sandgate Kendal Cumbria LA9 6HT Lead Inspector Ray Mowat Unannounced Inspection 14th April 2008 10:15 38 Sandgate DS0000036570.V362268.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 38 Sandgate DS0000036570.V362268.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. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 38 Sandgate Address Kendal Cumbria LA9 6HT 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) 01539 733465 01539 773073 www.cumbriacare.org.uk Cumbria Care Miss Lesley Jane Watson Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. An application in respect of a registered manager for this home must be received by the Commission for Social Care Inspection within 28 days of the date of this notice. A maximum of three younger adults with a learning disability (LD3) may be accommodated two of whom may be older with a learning disability (LD(E)2). When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. Staffing levels for the home must meet the Residential Forum Care Stafffing Formula for younger adults. 9th August 2007 2. 3. 4. Date of last inspection Brief Description of the Service: 38 Sandgate is a registered care home for up to three people with learning disabilities. The home is owned by Impact Housing Association and operated and managed by Cumbria Care, an independent business unit within Cumbria County Council’s contract services group. There were two residents in the home at the time of the inspection. Due to the high level of assessed needs of one of the residents, there is an additional sleep-in staff required, who is using the third bedroom. The home is in a quiet residential area on the outskirts of Kendal town, it is close to a bus route and local amenities. The home is a semi-detached property with a small front garden and a paved patio area to the rear. All the rooms are single occupancy with the bathroom and communal areas of the home being shared, although the downstairs bedroom has a fully accessible en-suite bathroom with a high low bath and toilet. The current fees for the home range from £515.50 to £2,155 per week. Information about the service is supplied to new and prospective residents in the service user guide. Inspection reports are made available to residents and their representatives and are displayed in the home. 38 Sandgate DS0000036570.V362268.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day. We (Commission for Social Care Inspection, CSCI) spent time with people living in the home and talking to them about their experiences. We also met with the manager and the staff on duty and looked at records relating to the running of the home and how people like to be supported to live their lives. We also sent out surveys as part of this inspection to get feedback from people living in the home, their relatives and representatives and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment, which provided information about all aspects of the running of the home. This included a self-assessment against the National Minimum Standards (NMS) recording what the home does well, what has improved and plans for the future. It also included information about policies and procedures, health and safety and information about the people living and working there. What the service does well: There are good systems in place that ensure there is a full assessment of people’s needs including specialist assessments. These are kept under review with changes in need recorded. Based on these assessments detailed person centred care plans and support plans are developed. These include action plans that are agreed with the person that help them to achieve their goals. There is a committed staff team who work closely with family and other professionals to make sure people get the support they need. Information relating to people’s communication needs is good, with the home working closely with the speech and language therapist to develop very personalised resources to improve the staff’s understanding of an individual’s gestures and limited verbal communication. This level of interaction and support is good practice and has been most beneficial to the individual concerned. Personal and healthcare needs are well documented enabling staff to provide unobtrusive support and promoting people’s independence and choice in their lives and providing them with a consistent and reliable service. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 6 A good range of risk assessments are in place to safeguard both service users and staff. People are enjoying a good quality of life and leading an active and fulfilling lifestyle. They are supported to pursue their interests and hobbies and have a good social life where they are able to mix with their peers and maintain friendships. They regularly access the facilities and amenities of the local community. Meals and mealtimes are very flexible and are planned around individual tastes and preferences. On the whole the home environment is safe and comfortable and suitable to meet the needs of the current residents. The new manager has settled in well and is aware of the home’s strengths and areas for improvement. What has improved since the last inspection? What they could do better: The information supplied to people living in the home must be reviewed and updated to ensure it is accurate, including the statement of purpose and service user guide. An up to date and accurate contract, for the provision of services and facilities by the provider to the service users, must be agreed with the people living in the home or their representative. This must clarify the home’s status as a registered care home. Currently there is confusion relating to who is responsible for the replacement of furniture and planned maintenance and decoration of the home. The manager must now produce a training and development programme for the home that will ensure staff receive suitable levels of training in line with the requirements of the Care Home Regulations and NMS. All staff must receive formal supervision at least six times a year. Currently supervision is taking place on an ad-hoc basis. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 7 The number of management or supervisory hours must be increased to ensure the home is managed effectively. This will improve staff supervision and support for staff in the absence of the manager. The kitchen table is worn with varnish peeling off and is in need of remedial action or replacement to ensure it can be properly cleaned. Guidance sheets should be completed for the application of all creams that are prescribed, to ensure staff are applying it consistently as directed. 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. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A detailed assessment of need is in place and kept under review ensuring the home is able to meet individual needs. However information about the home and the terms and conditions of residence is not accurate and must be reviewed an updated. EVIDENCE: The home’s statement of purpose and service user guide are not up to date and accurate and should be reviewed. The new manager Mrs Lesley Watson was aware of this shortfall and is planning a full review of the information contained. The people currently living in the home are very settled and enjoy a good quality of life. Key workers are being appointed who will work closely with the service users their families or representatives and other professionals, to ensure people’s needs are being constantly assessed, monitored and responded to. Prior to moving in, the home completes their own assessment in addition to any social work or specialist assessments that are in place. These are kept under review through the person centred care planning process with changes in need being recorded and incorporated into the person’s care plan. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 10 There was evidence the current residents are receiving housing benefit for paying rent and a service charge for heating and lighting, white goods, the fire alarm and replacement floor coverings. This situation is more in line with a ‘supported living arrangement’. The organisation is also receiving weekly payments from the Council for providing residential care ranging from £515 to £2,155. This situation must be reviewed as a matter of urgency to ensure people are aware of their rights, their terms and conditions of residence and that the organisation are meeting their legal obligations under the Care Home Regulations. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive person centred plans ensure individual needs and preferences are recorded and staff support people to achieve their goals in life. EVIDENCE: Comprehensive ‘support plans’ have been developed following the person centred care plan model. These include detailed information about a person’s life and what is important to them. They contain information relating to significant events in people’s lives; an informative pen picture; how people like to spend their time; important relationships; communication needs; support needs; religious and cultural needs. Based on this and other relevant information about personal and healthcare needs, action plans are agreed with the person and significant others in all the key areas identified. These are then recorded and monitored on an ongoing basis. Daily care notes and diary recordings make sure there is an accurate record of the care and support provided and significant events and activities. This 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 12 ensures a good continuity of care among the staff team and keeps people up to date with any changes. Staff take on an enabling role when supporting people to make sure they promote and support people to be independent in as many aspects of their lives as they are able. Staff work closely with families and advocates to ensure people’s views are represented and they are involved in all aspects of decision making. Despite one person having very limited verbal communication, on a day to day basis people are making everyday choices in their lives as well as contributing to more significant decisions. Detailed information relating to communication needs is recorded, with staff working closely with the Speech and Language Therapist to develop a greater understanding about how each person communicates and the meaning of their gestures and expressions. A talking photograph album has been developed, with staff recording interactions and liaising with the therapist, to build a clearer picture of what each word or gesture means in different environments. Staff are skilled at supporting people and promoting independence and choice and responding in a consistent manner. This level of interaction and support is good practice and has been most beneficial to the individual concerned. Personal support needs are also documented in detail to guide staff in supporting different activities and aspects of people’s lives. This again ensures a good continuity of care from the different care staff across the week. Team meetings are also used to good effect to share information and keep the staff team updated with regard to changes in people’s care and support needs. A good range of risk assessments have been completed that support an independent lifestyle whilst safeguarding both the individuals and staff. These have been kept under review and updated as the need arises. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 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. The people living in the home have a lot of autonomy to pursue their interests and hobbies and lead a fulfilling and independent lifestyle. EVIDENCE: Both the people living in the home attend a local day centre, which provides them with a good range of educational and social activities. They are able to mix with their peers developing friendships, which are important to them. They also attend other social clubs and events where they are again able to mix with their peers and enjoy the activities provided. One person is a keen sailor and is able to pursue this interest at the day service and through their contact with a local sailing club. When I met with them they also told me about another interest of theirs, cycling. They explained how they had recently “purchased a new bike and were looking forward to riding it”. This was something that was obviously important to them and gave them a real ‘sense of pride’. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 14 The home is also providing a good range of activities to meet the needs of individuals both in the home environment and in the local community. Within the home people are involved in different leisure activities and get involved with household chores such as sorting clothes, cleaning or preparing a meal. Recent examples of community activities recorded on individuals files included, going to a local football game, visiting family and friends, attending social functions with friends, attending a steam train rally, a candlelight parade and going to a quiz night. People are enjoying an active lifestyle of their choosing, joining in community activities and groups and were rightly proud of their achievements. Sound relationships are maintained within the home, with staff supporting service users in maintaining contact with friends & family and pursuing their cultural and religious beliefs. People have their own rooms where they could meet people privately with further potential for private meetings either around the kitchen table or in the lounge. They also have access to phone when required. Family and friends are welcome to visit the home at any time and both service users are taken to visit their families when they choose. Meals and meal arrangements are very flexible and based upon individual tastes and choices. Staff help people with their shopping and the preparation of food, with food choices made on a daily basis. Currently one person is on a weight reduction diet for health reasons meaning their intake is closely monitored. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. The home works closely with other agencies to ensure people’s personal and healthcare needs are being met and accurate records maintained. EVIDENCE: Comprehensive needs assessments are completed on admission to the home and kept under review to ensure changing needs are recognised and responded to. Personal and healthcare needs are well documented with person centred care plans and support plans in place for significant and routine healthcare needs and interventions by health professionals. They are both registered with a local GP of their choice as well staff as liaising with other relevant community health services or specialised services when required. This has recently included the community nurse team, speech and language therapist and the local hospital. They have provided advice and guidance to the staff, developed specific strategies to support people or provided aids and 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 16 adaptations to support and promote independence. This has been particularly effective for one person with regard to their communication. The staff team have received specific training, which focussed on specific strategies to guide them in supporting a person who can display quite challenging behaviour. This has helped staff to respond consistently to this person ensuring their dignity and independence are respected at all times. We examined medication records and the contents of the medication cabinet and on the whole these were well maintained ensuring people were being given appropriate support and guidance with their medication. There is a record of all medication entering or leaving the home and the contents of the cabinet are checked and signed by two staff each shift. MAR charts were up to date and signed. It is recommended that a PRN guidance sheet is completed for all creams that are prescribed, to ensure staff are applying it consistently as directed. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. People are safeguarded and well cared for and are confident their views or concerns are taken seriously and will be responded to. EVIDENCE: There is a clear complaints policy and procedure in place, which is also provided in an easy-read format. There have been no formal complaints recorded since the last inspection visit. However the manager explained in the AQAA how requests and comments that come up in conversation are routinely handled and resolved and don’t escalate into formal complaints. Feedback from the surveys sent out as part of this inspection confirms that people are aware of how to complain and who to complain to. There are clear policies and procedures in place around adult protection and all staff receive relevant training as part of their induction and foundation training. There are specific policies and strategies in place around areas of potential abuse and these have been incorporated into the relevant sections of a persons care plan, support plan and action plans. No adult protection issues or concerns have been reported. Support staff have received training in physical intervention specific to the one service user who has in the past sometimes needed to be protected from selfharming behaviours. The manager also confirmed the staff team had 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 18 completed recent training relating to recognising and responding to mistreatment and abuse but were awaiting the certificates. Appropriate security checks are completed on all new staff including Criminal Record Bureau checks, POVA first checks and two references, this ensures that staff are suitable for the role and people using the service are safeguarded. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 19 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, 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On the whole the home is safe and comfortable and is now suitable to meet the needs of the people living there. People rights and terms and conditions of residency need to be clarified, in relation to repairs and maintenance of the home and replacement of furniture. EVIDENCE: Since the last inspection the building work has been completed on the addition of an en-suite bathroom with high /low bath and toilet, to the downstairs bedroom. Although taking a lot longer than planned, the work has been completed to a good standard and provides a facility that promotes and supports an independent lifestyle. Although some of the decoration is dated, it is clean and hygienic and provides a safe and homely atmosphere. The kitchen table is worn and in need of remedial action or replacement to ensure it can be properly cleaned. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 20 The manager explained that the heating system is planned to be replaced during the current financial year including a replacement fire in the main lounge. Also the repainting of the outside of the home is planned, which is timely as it is starting to peel and look unsightly. As described in the first section of this report a review needs to take place to clarify the terms and conditions of residence, particularly in relation to the replacement of furniture and fittings and the decoration of the home, in line with the Care Home Regulations. Clear contracts must be developed and agreed that clarify people’s rights and who is responsible for the decoration, furnishing and maintenance of the home. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35, 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a stable and committed staff team who have a good understanding of people’s individual needs. Training and supervision must be improved to ensure staff have the skills and support to work effectively. EVIDENCE: All staff are required to go through a thorough recruitment process that ensures all the necessary checks and references are in place therefore safeguarding the people living in the home. They are issued with suitable contracts of employment and job descriptions when appointed and must complete suitable induction and foundation training. Staff job descriptions are clear and appropriately geared to meeting service user needs. GSCC Code of Practice features in the induction training received by all staff and underpin many of the policies relating to service user plans. Staff talked about a “Good induction that has improved”. Staff have developed good relationships with both service users and have a very good understanding of their day-today-needs and preferences. They are responsive to individual needs despite people’s limited verbal communication. There has been specific training around the needs of one service user that 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 22 included specific physical intervention techniques, autism awareness and intensive interaction that have been integrated into everyday practice. The home staff are working closely with other professionals to improve their understanding of one service users means of communication. This involves regular meetings between staff from the home, the day centre and a Speech & Language Therapist to agree and record definite meanings, location-specific meanings and meanings unique to particular individuals, and have begun to record some of these in a talking photograph album. This level of multiagency working is good practice and has been beneficial to the individual. We examined training and development records for staff, Continuing Professional Development Files. These reflected a minimal amount of staff training taking place in the last twelve months, although the manager did confirm more training had taken place than was recorded. Feedback from staff surveys confirmed that training had not been taking place regularly. “Training is sparse and infrequent”, “I have been offered one course in the last twelve months”. The manager must now produce a training and development programme that will ensure staff receive suitable levels of training in line with the requirements of the Care Home Regulations and NMS. We also examined staff files and found that supervision records were inconsistent with long gaps between meetings. Staff were not receiving supervision within the required timescale, as one person said, “Supervision is patchy”. The manager acknowledged the training and supervision shortfalls and said she was aware of the problem. However due to the volume of work she was currently undertaking, which had been increased by the building project and only being on a 12 hour contract, she had found it difficult to keep up to date with everything. The previous acting manager had also worked care shifts in the home that appears to have masked this problem, which must now be addressed. The manager said that a supervision date and annual appraisal were planned to take place before the end of June 08. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 23 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, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of the people living there, they are safe and well cared for. Management/supervisory support must be increased to ensure the home is managed effectively. EVIDENCE: The new manager Mrs Lesley Watson has completed the registration process with the Commission. She is suitably experienced and qualified for the manager’s role. In a short period of time she has “got to grips” with her role and has a clear plan of the priorities for the future. The AQAA that she completed was detailed and gave an honest evaluation of the strengths and areas for improvement within the home. It is evident with only twelve hours a week to manage the home and not having a supervisor or senior carer to take responsibility in her absence, the potential for improvement is very limited. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 24 The number of management or supervisory hours must be increased to ensure the home is managed effectively and staff receive the supervision and support they require. The other major issue for the manager is to resolve the anomalies regarding the status of the home as a registered care home and meeting their statutory responsibilities in maintaining the home. There are both formal and informal systems in place for consultation with people living in the home. This ensures “their voice is heard” and they contribute to all aspects of the running of the home. Care staff have developed good relationships with people and their representatives and are skilled at communicating with them and respecting their thoughts and wishes. Regular team meetings are held which are valued by staff and enable them to share relevant information and maintain a good continuity of care. The organisation keeps all policies and procedures under review in line with changes in legislation and good practice guidelines. Routine maintenance and servicing records were up to date including the fire log and fire drills for staff and service users. There is a maintenance log that records all repairs ensuring they are reported and resolved in a timely manner. The home provides a safe and comfortable living environment and there were no obvious hazards noted on this visit. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 3 4 X 5 2 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 2 25 2 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 2 X 2 3 3 X 3 3 X 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA5 Regulation 5 Requirement An up to date and accurate contract, for the provision of services and facilities by the provider to the service users, must be agreed with service users or their representative. The manager must now produce a training and development programme for the home that will ensure staff receive suitable levels of training in line with the requirements of the Care Home Regulations and NMS. All staff must receive formal supervision at least six times a year. The number of management or supervisory hours must be increased to ensure the home is managed effectively. Timescale for action 01/07/08 2. YA35 18 (1c)(i) 01/07/08 3. YA36 18 (2) 01/06/08 4. YA37 18(1a) 01/08/08 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA24 YA20 Good Practice Recommendations The information supplied to people living in the home must be reviewed and updated to ensure it is accurate. The kitchen table is worn and in need of remedial action or replacement to ensure it can be properly cleaned. It is recommended that a guidance sheet is completed for the application of all creams that are prescribed, to ensure staff are applying it consistently as directed. 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 38 Sandgate DS0000036570.V362268.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!