Inspection on 23/05/07 for 4 Seafarer`s Walk

This inspection was carried out on 23rd May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 Seafarer`s Walk 27/06/06

4 Seafarer`s Walk 12/09/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 4 Seafarer`s Walk Sandy Point Hayling Island Hampshire PO11 9TA Lead Inspector Ian Craig Unannounced Inspection 23rd May 2007 12:00 4 Seafarer`s Walk DS0000064985.V336114.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 4 Seafarer`s Walk DS0000064985.V336114.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. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 4 Seafarer`s Walk Address Sandy Point Hayling Island Hampshire PO11 9TA 0151 420 3637 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) www.c-i-c.co.uk. Community Integrated Care Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: The home is situated in a quiet residential area to the southeast of Hayling Island and within easy each of the beach. Local shops and amenities can be accessed, but to use a wider range of facilities travel is necessary to locations off the island such as in Portsmouth, Southsea and Havant. The home is purpose built and is situated next to a similar registered home. The homes share the front car park. All of the facilities are provided on one level with the exception of the garden. This slopes away to the front and rear of the home making independent use difficult and restricting the amount of usable space. The home is suitable for people who have physical as well as learning disabilities. All of the service users have single rooms. They have use of the kitchen /diner, a lounge and another room known as the recreation room. The home has one bathroom and a separate WC. The inspector requested details of the fees but the manager did not provide these. The fees, as given in April 2006 were £1312 per week. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection consisted of a tour of the building, discussion with the manager and examination of records and documents as well as policies and procedures. Two staff were interviewed about their work at the home. Two residents were spoken to, one of whom was briefly interviewed. Upon arrival at the home two further residents were taken to college to attend a course. Staff and residents were observed. Questionnaires were sent to the home for relatives to make comments about their views of the home. None of these were returned. Part of the inspection process involves the service completing and returning an annual assessment. This was not returned by the due date despite a reminder letter being sent. During the inspection the manager was asked if she could return the annual assessment, but failed to do so. What the service does well: The home’s Statement of Purpose and Service Users’ Guide are in an ‘easy’ read format so that they are accessible to residents. There are plans to convert these documents to a recording on a compact disc, which will be given to each person. Residents’ records and care plans are of a good standard showing that individual care, health and social needs are addressed. Care plans are written with the service user as the focus and include cultural and religious needs. Records are also maintained to show that each person’s health needs are addressed. The home liaises with health and social services regarding the monitoring and reviewing of each person’s needs. Each of the residents has a programme of activities, which includes access to leisure, social and educational facilities. Staff receive training in dealing with specific behaviours, and individual care plans include guidance for staff to follow when certain situations arise. The home’s procedures for safekeeping and assisting resident’s with their finances are of a good standard. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The physical environment is in need of particular attention. The only bathroom is in need of refurbishment as a matter of priority. The floor is damaged and the shower has been decommissioned due to a need for repairs. The kitchen also needs to be refurbished. Units are chipped and one wall is unsightly where a unit has been removed. The home accommodates residents who have significant mobility needs. Access to the garden and in the garden itself is poor with uneven and inadequate surfaces, slopes and a lip on door threshold. Nighttime staffing levels need to be reviewed, as it is unclear if the present arrangements are sufficient to meet the needs of the residents. Whilst records show that staff receive training, this was not the case for the induction of newly appointed staff. Training for staff could be improved by the provision of a course in mediation for the home’s senior staff, and courses for staff in specific care needs such as communication, personal care, behaviour and sexuality. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 7 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. 4 Seafarer`s Walk DS0000064985.V336114.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 4 Seafarer`s Walk DS0000064985.V336114.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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information about the service. Regular reviews of care, health and social needs help ensure that residents’ needs are met. EVIDENCE: The home has a Statement of Purpose and a Service Users’ Guide. These give residents, and their relatives, information about the service provided, including charges, activities, the complaints procedure, availability of the Commission report on the home, how often rooms will be redecorated and so forth. These documents make use of photographs of the home’s environment and pictorial diagrams to aid communication with residents. These documents are written with the residents as the focus. For instance, the following is stated: Your room will be decorated and you will be able to choose the colours. The manager explained that the home will be providing each resident with a compact disc version of the Statement of Purpose and Service Users’ Guide in a verbal format. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 10 The home has not admitted any new service users since 1991. It was therefore not possible to assess the process of admitting residents to the home. For the existing residents, care and social needs are regularly reviewed by both the home and social services’ care managers. Records and copies of reviews are held with each resident’s records. It was also clear from discussions with the manager and staff, and from records, that the home liaises with relevant health and social services professionals for specific needs. Each resident has a copy of a contract as well as a licence agreement for their stay at the home. An additional contract is signed by residents regarding the charge for the mini bus. This arrangement and fee is also detailed in the Service Users’ Guide. 4 Seafarer`s Walk DS0000064985.V336114.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s individual care plans and risk assessments are comprehensive and of a good standard, showing how care and social needs are to be met. The home takes steps to ensure that residents are supported to make decisions about their lives and are involved in decision making in the home. EVIDENCE: The assessments and care plans for three residents were examined. These include assessments of various needs with corresponding care plans of how those needs are to be met. Care plans cover the following areas: • Behaviour management • Emotional needs 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 12 • • • • • • Health Money management Health and safety Religious/cultural/ethnicity Personal care and support Social/leisure/holidays There is evidence in the care plans of the involvement of residents and of regular reviews taking place. Each resident has a section of care planning entitled My Health Care Needs, which is in pictorial diagram format and places the resident at the centre of any appointments and decisions. Risk and vulnerability regarding behaviour, activities, the environment, money management, capacity to make informed choices are assessed and recorded with corresponding guidance for staff to follow. Evidence in care plans and daily running records shows that residents are able to make decisions about what they would like to do. Each resident has been able to have his or her bedroom decorated in a colour scheme of their choice. Residents are able to choose meals but with staff guidance so that a nutritious diet is provided. During the course of the inspection residents were observed spending their time as they chose to. The inspector observed that residents felt comfortable approaching the staff to express their needs and wishes. The manager stated that the family of one resident has reported an improvement in the behaviour of their relative who lives at the home. This could not be evidenced in a care review or from any ‘feedback’ forms. 4 Seafarer`s Walk DS0000064985.V336114.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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities for developing independent living skills and lead full lives where a variety of social, leisure and educational activities are arranged, based on each person’s needs and wishes. EVIDENCE: Records, care plans and discussions with the staff and manager confirmed that residents are able to maintain and develop independent living skills. Each resident has a care plan entitled, The Essential Lifestyle Plan, which emphasises the person’s strengths and skills and how these can be developed according to the person’s wishes. For example, education and cooking skills are assessed and how these can be enhanced. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 14 Three residents attend a college. At the time of the inspection 2 residents left to attend an afternoon course in music and movement at Chichester College. Daily running records show that each person engages in a variety of activities and that individual choices for the residents are acknowledged. The home has a staff member with responsibility for coordinating activities. There may be scope to improve the provision of activities as one staff member felt that residents should be given more opportunities for outings, and the daily running records showed that 2 residents may benefit from closer attention to organising activities on ‘free’ days when motivation is an issue. Residents are able to benefit from use of the home’s mini bus. A charge of £30.00 per month is made and details of this are included in the Service Users’ Guide and in a contract with each person. A charge for individual journeys is not made. Each person has the opportunity of a holiday, which is arranged individually based on the assessed needs of the person. Two staff recently escorted a resident to a holiday in Florida, another resident has a 4-day holiday at Butlin’s, another a holiday in Cornwall accompanied by staff, and one person has a week’s holiday with his/her parents. For those who do not wish to, or are unable, to have a holiday, day trips are arranged. The home provides an annual holiday budget to each resident of £375.00. Residents maintain links with families and friends. Details of emotional and sexual needs are assessed and recorded. Specific monitoring and liaison with social service is arranged when required. The inspector advised the manger that staff and residents may benefit from specific training in dealing with the sexual needs of those with a learning disability. The home has a menu plan showing a varied nutritious and balanced diet. Food stocks were seen to be ample and included fresh fruit. One staff member is trained in nutrition. 4 Seafarer`s Walk DS0000064985.V336114.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met. EVIDENCE: Details of personal care needs are recorded in care plans and include reference to any hygiene and care matters. Each resident has a specific care plan for health. Additional records show that each person has appointments for the following: dentist, optician, general health care with a general practitioner, podiatrist and mental health professionals. At the time of the inspection a resident had returned from to the home following dental treatment. The home’s medication procedures were examined. Staff receive training from the home’s manager and deputy manager. The manager and deputy have not 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 16 attended any formal training in medication and provide the training to staff based on their previous experience. The inspector advised that it would be beneficial to the staff and residents if those providing ‘in house’ medication training to staff attended a training course. Each staff member’s competency in medication is assessed and this is recorded. Medication recording sheets show that medication is administered as prescribed. Guidelines are recorded for staff to follow when medication ‘as required’ is administered, including medication for behaviour. It was noted that guidelines could not be located for one medication ‘as required.’ 4 Seafarer`s Walk DS0000064985.V336114.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, views are listened to and they are protected from possible harm and abuse. EVIDENCE: The home’s complaints procedure is contained in the Statement of Purpose and in each resident’s contract, which is signed by the resident. Training is provided for staff in the principles and procedures of protecting vulnerable adults from possible abuse. This was confirmed from records and discussion with staff members. Staff are trained in strategies for dealing with possible aggressive and challenging behaviour. This was evidenced from records and discussions with staff. Where this is an identified need for a resident, care records set out the specific behaviours and how staff should respond. The home assists residents in dealing with their finances. Records of any monies handled by the home are well maintained and show that each person is 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 18 able to access their bank accounts with staff help. Valuables are securely stored and there are procedures and records for checking any resident’s money held by the home by two staff twice a day. This was evidenced by records, observation of storage facilities and discussions with the manager. 4 Seafarer`s Walk DS0000064985.V336114.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, 26, 27, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst improvements have been by redecorating residents’ bedrooms, the bathroom is in a state of disrepair and access to the garden is not good and is potentially hazardous for residents. EVIDENCE: Each of the resident’s bedrooms was seen. These have been redecorated in colour schemes chosen by the residents. It was clear that residents are able to express themselves in their bedrooms by having personal possessions, pictures, ornaments and other items related to personal interests. The communal hallways have been made more homely by the installation of carpets on floors that were previously tiled. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 20 Residents were observed using the lounge and their bedrooms. It was clear that residents are able to access communal and bedroom facilities with staff giving discreet support. Improvements are needed so that residents with mobility needs can safely access the garden. This was raised by the staff and the manager. The rear garden has a ramped access to a an area which residents can sit in, but the majority of the rear garden is sloping and cannot be accessed by those with mobility needs. It was also pointed out to the inspector that access to the rear garden via the sliding patio doors was difficult due to the door rise/step. In order to improve the access for residents to the garden a patio deck has been built in the front garden. However this is in a state of disrepair and access is across an uneven lawn. The manager stated that this will be improved by the installation of a walkway to the deck patio. The home has one bathroom. The shower has been decommissioned due to its poor state and the surrounding linoleum is ripped posing both a tripping and infection hazard. Areas of the ceiling have mildew and the bath is showing signs of wear and tear. A chair lift has been installed on the bath so that those with mobility needs can use it. The kitchen/dining room is also in need of attention. Kitchen units are chipped and worn. On one wall kitchen units have been removed, holes filled but the wall not redecorated. The inspector was informed by the manager that the Environmental Health Officer recommended a general updating of the kitchen The home has a laundry utility room with a sluice washer and drier. 4 Seafarer`s Walk DS0000064985.V336114.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): 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents benefit from the training provided to staff, this should be developed further in order that staff have a greater knowledge of specific needs and how this can improve the lives of the people who live in the home. It was unclear if sufficient staff are deployed at night time to meet the needs of the residents. Staff recruitment procedures show that residents are protected with the exception of those employed on an occasional basis. EVIDENCE: The home provides 3 staff from 7.30am to 10.00pm each day with one staff member on waking duty at night time. This was evidenced from the staff rota, observations, and from discussions with the staff and manager. The use of 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 22 agency staff in the home has declined, which allows for a greater continuity of staff for the residents. The issue of whether or not the night time staffing is sufficient to meet the needs of the residents was discussed. The manager felt that the current arrangement is adequate but not if one or more of the residents requires help for any incident involving challenging behaviour or significant personal care. The manager stated that she has raised this with the organisation, but with no outcome at the time of the inspection. Staff described the home as having a good working atmosphere with an emphasis on team working. Management were said to be approachable and that staff are encouraged to share their views about the home. A staff member demonstrated a motivation and enjoyment of her/his work with the residents. Staff and management were observed to interact well with the residents. Each staff member has a Training and Development Programme as well as a record of training courses attended. This showed training in moving and handling, first aid, food hygiene, NVQ level 3 and adult protection. Staff stated that the service provides access to various training courses. Residents would benefit from staff undertaking training related to the specific needs of the residents, such as sexuality and behaviour. Recruitment procedures were checked. These show that staff undergo the required checks such as criminal record bureau and protection of vulnerable adults checks. Each staff member completes an application form and has an interview. Records show that an interview assessment and score sheet is completed. The home uses staff from its own pool of relief staff to cover any absences. One staff member was employed on this basis for approximately 40 hours a week at the time of the visit. For these staff there are no records available to verify that the necessary checks have been carried out before the person commences work. A relatively newly appointed staff member confirmed that he/she had a period of induction where she was ‘shadowed’ for 2 weeks. The home did not have a record of any induction for the person despite commencing work 6 months prior to the visit, although the home’s diary confirmed he/she had attended first aid and food hygiene training. The manager stated that staff induction is recorded by staff on an interactive programme on the organisation’s staff website, but is only available to the respective staff member. The inspector confirmed that the home must be able to demonstrate that newly appointed staff have received instruction and training to a standard that residents’ needs can be met. 4 Seafarer`s Walk DS0000064985.V336114.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, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to the home’s management to ensure that the home runs in the best interests of the residents. EVIDENCE: The home has had a new manager since October 2006. The Commission records do not show that the organisation notified the Commission of the new management arrangements. In addition to this, the new manager has not yet applied for registration with the Commission. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 24 From discussions with manager and members of the staff team, as well as from examination of records, it is clear that the manager has introduced changes and improvements to the service that improve the quality of life for the residents. These include the redecoration of residents’ bedrooms and improvements to the care plans. The home does not have a quality assurance system although monthly visits are carried out by a member of the organisation’s management team when an audit and report are completed. The views of relatives and residents are not obtained by the use of a survey, although care reviews take place which relatives often attend and can express their views. The home does not have an annual development plan. Staff receive training in moving and handling, food hygiene, first aid and infection control. Records and documents show that the following are serviced in accordance with health and safety guidelines: electrical appliances, gas heating and the fire alarm system including emergency lighting. The home has a fire safety risk assessment. Records show that regular fire drills and staff fire instruction take place. Measures have been taken to protect residents from hot surfaces such as radiators and from scalding by hot water. 4 Seafarer`s Walk DS0000064985.V336114.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 3 2 3 3 X 4 X 5 3 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 X 26 3 27 1 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X 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 3 X 2 X 2 X X 3 X 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23 Requirement The registered person must provide suitable bathing facilities to meet the needs of service users. This is a repeat requirement of 12/11/05 and 31/12/06 as the requirement has been partially met. The bathroom must be refurbished, including the shower and flooring. 2 YA24 23 Repairs must be made to the damaged walls in the kitchen. Replacement of the kitchen units must be included in a plan of refurbishment of the kitchen. 3 YA29 23 Arrangements must be made so that those with mobility needs can safely access the facilities in the garden. An assessment of the physical environment by an occupational therapist, or someone trained in this area, must be carried out. 23/08/07 23/08/07 Timescale for action 23/08/07 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 27 4 YA33 18 A review of the staffing levels at night time must be carried out to ensure that the needs of residents can be met during this time. The home must be able to demonstrate that those staff employed as part of the organisation’s relief team have undergone the necessary recruitment checks. Staff records as required by the regulations must be available in the home. This can include the completion of a pro forma as set out on the commission website so long as written agreement with the Commission is obtained. 23/08/07 5 YA34 19 schedule 2 and 4 23/07/07 6 YA35 18 The home must be able to demonstrate that newly appointed staff have received the necessary induction, guidance and training to be able to work in the home by maintaining records. The home must implement a system of quality assurance involving obtaining the views of residents and their relatives, an audit and annual development plan. 23/08/07 7 YA39 24 23/08/07 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 YA18 Good Practice Recommendations Staff should attend training in specific care needs such as DS0000064985.V336114.R01.S.doc Version 5.2 Page 28 4 Seafarer`s Walk sexuality, behaviour and learning disability. 2 YA20 Those staff providing training to care staff in medication procedures should receive training in medication that qualifies them to train staff. 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 4 Seafarer`s Walk DS0000064985.V336114.R01.S.doc Version 5.2 Page 30 - 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!