Inspection on 08/08/06 for 5 Seafield Road

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 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

5 Seafield Road 10/11/05

5 Seafield Road 07/06/05

5 Seafield Road 13/12/04

5 Seafield Road 12/07/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 5 Seafield Road 5 Seafield Road Seaton Devon EX12 2QS Lead Inspector Belinda Heginworth Key Unannounced Inspection 8th August 2006 08.55 5 Seafield Road DS0000021859.V306403.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 5 Seafield Road DS0000021859.V306403.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. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 5 Seafield Road Address 5 Seafield Road Seaton Devon EX12 2QS 01297 22423 01297 24641 Seaton@sense.org.uk 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) Sense Ms Dorothy Sharp Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager must obtain NVQ level 4 in care and the Registered Manager’s Award by the 30th December 2007. 10th November 2005 Date of last inspection Brief Description of the Service: Seafield Road cares for people with significant sensory impairments who may also have a learning disability, complex and diverse needs, and/or a physical disability. The home is a large converted terraced property close to the centre of Seaton. Bedroom accommodation is on three levels. The third floor also has a sensory room and two offices. There are two ground floor bedrooms that are suitable for wheelchair users. However, the home does not have a lift and therefore the upper floors are unsuitable for anyone with mobility difficulties. Wheelchair users cannot access the sensory room or activities room. There is a ramp to the dining room to enable wheelchair users easy access to this room from the ground floor, but there are two steps down into the kitchen that cannot be ramped, and therefore wheelchair users can only access this room via an outside ramp. To the front of the property there is a small garden area and to the rear there is a pleasant, paved patio area and a sensory garden with raised flowerbeds and swing bench. The home is run by a national organisation Sense, who provide registered care homes and other services for people with sensory impairments and learning disabilities. Information received from the manager prior to the inspection indicates that the home’s fees are £93.996 per year. Additional costs are charged for transport at 60 of service users’ Mobility Allowances. Inspection reports are available to relatives and professionals upon request. Service users currently would be unable to read CSCI reports due to their communication difficulties. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6.45 hours with the manager being present throughout. The inspector would like to thank service users, the staff team and management for a warm welcome and help throughout the inspection. The people living at Seafield Road have significant sensory impairments and extremely limited verbal communication skills. They were therefore unable to contribute verbally to the inspection process. Significant time was spent with service users and observations were made during the inspection. Prior to the inspection the manager completes a questionnaire, which provides information about service users, staffing, fees and confirms that necessary policies and procedures are in place. Surveys were sent to service users and staff prior to the inspection. Comment cards were also sent to professionals who are connected to the home and questionnaires were sent to relatives. Three service user surveys were returned, which were completed by relatives. One relative questionnaire was received and telephone contact was made with one relative. Five staff surveys were returned and three comment cards were received from professionals involved with the home. All comments received were very positive about the home and the services. The inspector looked around parts of the building and some records were inspected. What the service does well: The atmosphere in the home is warm, relaxed, friendly and fun. Service users appeared to have good relationships with the staff and were relaxed and happy. Staff were observed being kind, caring and very patient and gentle in their manner. Staff were observed offering choices to services users and were communicating with service users according to their communication needs and were sensitive to their complex and diverse needs. The home has enough information about service users prior to admission to establish if the home can meet that person’s needs. Once a service user is admitted the manager provides good written plans of care that take into account service users’ needs, risks, wishes and goals. This ensures staff are provided with information that helps them meet service users’ needs safely and consistently. The staff team are committed, caring and respectful at all times, this was observed throughout the inspection. Service users use the local and surrounding areas to attend a wide variety of activities, educational and leisure 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 6 pursuits. Service users are also supported to maintain good family contact and visits. A wide, varied and healthy diet is offered to service users, which some help to shop for and prepare. Staff are recruited appropriately and receive training appropriate to meet service users needs and protect their safety and welfare. The home is well managed and run in the best interests of service users. The manager monitors the quality of care regularly and seeks the views of service users, relatives and outside professionals to ensure the home is being run in the best interests of service users. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 5 Seafield Road DS0000021859.V306403.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 5 Seafield Road DS0000021859.V306403.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The manager gathers enough information to ensure the home is able to meet service users’ needs prior to admission and provides good information prior to admission. EVIDENCE: The home has a Statement of Purpose that provides relatives and professionals with information about the home. The manager has also produced this information in formats suitable for the communication needs of service users with a learning disability, for example, in larger print and videotape. The service users living at the home have done so for a number of years. Detailed assessments were carried out prior to admission. This enabled the home to establish whether they were able to meet the service user’s needs. Relatives confirmed they were involved in the process and had received good information about the home. Carers confirmed that there was good information about service users to help them understand their needs. Each service user is provided with Terms and Conditions of occupancy. This ensures that service users or their representatives know what services will be provided within the fee structure. 5 Seafield Road DS0000021859.V306403.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are provided with excellent information to meet service users’ needs and goals safely and consistently. EVIDENCE: Each service user has a plan of care and recorded information about their needs. This includes – “an introduction to me”, a history, how they communicate, what they enjoy doing, behavioural guidelines, basic vision and hearing information, important people in their lives, “my best and worst days”, “things I like and don’t like to do”, which includes food and nutrition, a pen picture, how to support the service user, health action plans, how to support them in complaints and objects of reference. Agency staff are also provided with a summary of important guidelines they need to know to help meet service users’ needs safely. Relatives and a care manager confirmed that regular reviews take place, which they intend. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 10 All decisions made on behalf of service users are agreed and discussed with relatives and care manager, particularly those that may infringe upon service users freedom of movement or privacy. Good records of such decision-making processes are recorded and reviewed regularly. Any risks to service users through general health, needs or activities are assessed and clear action to reduce any risks are recorded. Staff were able to accurately describe the content of care plans and risk assessments. They demonstrated an excellent understanding of each service users’ needs and risks. They were observed being respectful, caring and sensitive to each person’s individual needs. The levels of staff on duty ensure that service users’ needs and goals are met appropriately. This was observed throughout the inspection. There is a high level of staff training within the home that is arranged around service users’ needs, ensuring they are met appropriately. Due to the complex and diverse needs of each service user some restrictions of their freedom of movement and sometimes privacy has been implemented. For example, the stable door from the dining room to the kitchen is bolted at the bottom when there is no staff in the kitchen. Through observations it was clear that service users would be at risk of harm if they entered the kitchen unsupervised. However, service users were seen using the kitchen when staff were supervising them. The decision to have this restriction had been discussed and agreed with relatives and care managers and is reviewed regularly. Another example is the use of listening devices for two service users. This is due to their complex health needs and is only used at night. Although there are other systems in place to monitor these particular health needs the listening devices were said to prevent those service users from harming themselves by falling out of bed or injuring themselves while moving around or when unwell. Again this had been discussed and agreed with relatives and care managers and is reviewed regularly. Staff were also aware that service users may need private time at night and the listening devices could prevent this. However staff were sensitive to this and said the devices would only be switched on when needed. 5 Seafield Road DS0000021859.V306403.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from accessing the local community and taking part in appropriate activities. Service users rights are respected at all times. Service users benefit from a varied diet. EVIDENCE: The high levels of staffing enables service users to be supported individually to gain access to the community and attend activities suitable to their needs. On the day of the inspection two service users with two staff went to Exeter to do shopping and have lunch out. One service user in the home had a story read to them by a staff and music of his choice was played throughout the morning. Another service user was helped to create and make a weather dial. Another service user was supported to use the garden and go to the local park. The fourth service user had a sleep on the sofa and then enjoyed playing with a basket of “toys”, while the member of staff described what she was picking up. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 12 Throughout a time of observations staff were seen to be respectful, kind, and very gentle and relaxed in their manner. Staff were patient and considerate at all times. An example of this was observed when the sun was shining through the lounge onto a service user. The staff asked if that was annoying and hot for them and closed the curtain to prevent the service user becoming too hot. Another example was when the inspector first arrived a service user with no sight was coming down the stairs. Staff were encouraging, patient and supportive throughout the process. Service users were observed throughout the inspection as being relaxed, happy and responded well to staff. Activities range from walks, swimming, trampolining, college and many more. The home has an “aqua cabin”, which provides an aromatherapy / massage shower. Two staff job share as activity co-ordinators. Their job is to ensure that activities suitable to each person’s needs are found and carried out. Staff complete a record of activities achieved and regular reviews are carried out to ensure the activity continues to suit the person’s needs. In each resident’s bedroom a list of how they like to be approached, moved and their preferred routine is recorded. This is particularly useful for new and agency staff. It was clear that staff had an excellent understanding of service users’ communication needs and worked hard to ensure service users were understood and their needs and requests were met. The home has two vehicles for transportation. Service users are charged approximately 60 of their mobility benefits. Relatives and care managers were consulted about the charges and agreements were reached. The home has a policy for the use of the transport and the manager is currently auditing its use to ensure that service users have equitable use. Relatives confirmed that staff support service users to maintain contact with them through visits and the manager keeps them informed of any changes or concerns. During observations at lunch time staff were seen to offer service users choices and where service user had little or no sight enabled them in eating, explaining all of the time what food they were about to eat. The atmosphere throughout the meal was relaxed and service user focused. All foods are prepared with the knowledge of service users’ likes and dislikes. Drinks and snacks were offered throughout the day. A record of all foods eaten are recorded and monitored to ensure service users receive a healthy and balanced diet. 5 Seafield Road DS0000021859.V306403.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are well met. Service users’ dignity and privacy is respected. EVIDENCE: Staff had a good knowledge of how service users preferred to receive personal care. Care plans and information in service users’ bedrooms provide staff with information on personal care and how much support is necessary. There were excellent records of service users’ health care needs and how they are monitored. Each service user has a health action plan that clearly describes their health needs and how they should be monitored. There was good evidence to such monitoring takes place. Service users are supported by staff to attend medical appointments. Medication storage and administration records were accurate. All staff that administers medication have received appropriate training and their competencies are assessed by the manager to ensure they understand the training they have received and remain safe to administer medication. These assessments are completed six-monthly. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 14 Some complementary medicines are researched and used by the home, in consultation with GPs, relatives and service users’ representatives. An example of this was in relation to a service user with poor sleep patterns. This was mainly due to their vision impairment. The deputy manager had researched this and found a complimentary medicine that showed positive results in similar cases. This was discussed with the appropriate people and tried. The response resulted in an excellent outcome for the service user both day and night, which has had a positive impact on all aspects of there live. 5 Seafield Road DS0000021859.V306403.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are fully protected from abuse. EVIDENCE: The home has received no complaints since the last inspection. The complaints policy is explained to service users who are able to understand. The policy is available in various formats to suit service users’ individual communication needs. One service user has the complaint’s policy in widget form and staff explain the procedure regularly to ensure it is understood. Relatives said they felt confident that any complaint or concern they had would be dealt with properly. Staff knew and understood the complaints policy and felt confidant that any issues they had would be dealt with appropriately. They were also aware of information within service users’ care plans that provided guidelines on how to support that service user to make a complaint or voice their concerns. All staff have received training on adult protection awareness. Staff demonstrated an excellent understanding of abuse issues and knew what to do if they suspected any. Staff were able to describe all types of abuse and also highlighted subtle forms of abuse. During staff’s one to one supervision with senior staff, it is standard practice to highlight and discuss protection and abuse awareness issues. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 16 The home recently had an adult protection issue, which was dealt with appropriately, effectively and efficiently, involving outside professionals and following Adult Protection procedures. Service users’ finances are managed well and fully protect service users from potential financial abuse. Each service user has a bank / building society account. Benefits are paid directly to Sense and the balance of monies belonging to service users is paid to their accounts. Any cash held in the home on behalf of them is clearly recorded with receipts. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a clean and homely environment. EVIDENCE: The home is decorated, furnished and equipped to meet the needs of the service users and has a warm and homely atmosphere. In addition to personalised bedrooms service users can use a sensory room, an Aqua-cabin, the dining room and bright lounge. The dining room is painted brightly but has no pictures on the walls due to some service users who pull things off and are at risk of harming themselves. Discussion took place about perhaps painting pictures on the wall to make it that little bit more homely. Throughout the home there are objects of reference to help service users with sensory impairments find their way around. For example, bathrooms have a sponge outside to enable service users to feel and distinguish it from other rooms. Every bedroom and the front door has a door bell that also makes the light flash to enable service users with poor or no hearing know when someone wants to come in. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 18 A scent is used each day to enable service user to distinguish what day of the week it is. The upper floors can only be accessed by service users with good mobility. One wheelchair user has a shower room but cannot use the bathroom with bath or the sensory room. For many years Sense have tried to resolve this with structural engineers but have been unable to come up with a suitable solution. Consideration has even been given to finding a home that would meet this person’s physical needs. However the service user had become very unsettled and unhappy with this and has made it clear they are happy living in the home with the facilities they have and does not want to move. The manager has maintenance, decoration and development plan to ensure the house remains suitably decorated and maintained. The manager hopes to turn one of the offices into another sensory / relaxation room. On the day of the inspection the home was clean, tidy and fresh. The laundry room, which is situated outside of the home, was clean and tidy. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by enough caring and trained staff to meet their needs. Service users are protected by robust recruitment procedures. EVIDENCE: The home provides a high level of staffing to ensure service users’ needs, including social needs are met. During the week there are five carers on duty in the morning and four in the afternoon and evening. At night there are two staff on duty, one awake and one sleeping in. Some service users receive one to one staff. At weekends there are four staff on duty in the morning, afternoon and evenings. This is mainly because organised activities, college and so on is less and some service users receive visitors or go home to families. It was clear through observations made that service users’ needs were being adequately met with this high staffing level. Relatives and care managers who provided feedback felt service users’ needs were being met safely and appropriately. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 20 Staff receive excellent training to help them meet service users’ needs appropriately and safely. Some examples are: British sign language, epilepsy, total communication, adult protection, mandatory health & safety training, sexuality and relationships, safe administration of medicines and many more. Responses to questionnaires sent to staff indicated that the training provided by Sense and the manager of the home was good and helped them to meet service users’ needs. Recruitment procedures fully protect service users from potential abuse. Appropriate checks are made prior to someone working in the home, in including police checks. Interviews are carried out with relatives and independent managers as well as the home’s manager. Induction training is provided by Sense prior to the person working in the home and an additional induction relevant to the home and service users is completed by the manager and deputy. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of service users. There are excellent systems to review, develop and improve the home. Service users safety and welfare are well protected. EVIDENCE: The manager has been working in the position of registered manager for over a year now. She has almost completed the Registered Manager’s Award and is in the processing of doing NVQ level 4 in care. Staff spoke very highly of the manager and deputy and said they felt well-supported and received clear direction and leadership. The manager and staff are very service user focused and ensure the home is run in the best interests and needs of service users. This was observed throughout the inspection and has been reflected throughout this report. Relatives, care managers and other professionals provided positive feedback of the manager and the home in general. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 22 The manager has excellent systems in place to monitor and review the quality of care delivered to service users. This includes satisfaction surveys to relatives, outside stakeholders and staff. Service users are monitored regularly through care plan reviews and individual discussions and observations. Staff training and assessments of staff practices ensure the home continues to run in service users’ best interests. Sense carries out monthly inspections and quality assurance audits are completed yearly. One year this is completed by the organisation and the following year it is completed by a self-assessment. The assessment includes scoring under topics such as person centred approaches, lifestyles, specialist approaches, privacy and dignity, environment and many more. An action plan for low scores must be produced with time scales and named people responsible for carrying out the action. In addition to this, good practice sharing days are arranged between all Sense home managers. The fire logbook was found to be up to date and accurate. Fire risk assessments and most staff training were completed, therefore protecting service users safety and welfare. The CSCI obtains information prior to inspections. The information includes conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. In this instance policies and procedures were in place. These along with risk assessments are reviewed regularly and are up dated where necessary, to ensure they are appropriate and reduce risks to staff and service users. 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 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 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 4 X X 3 X 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 24 N/A 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. Refer to Standard Good Practice Recommendations 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 5 Seafield Road DS0000021859.V306403.R01.S.doc Version 5.2 Page 26 - 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!