Inspection on 07/12/05 for Lakeside House

This inspection was carried out on 7th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lakeside House 18/07/07

Lakeside House 22/09/06

Lakeside House 22/08/05

Lakeside House 23/03/05

Lakeside House 09/06/04

Similar services:

32 Beaumont Way

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Somerset Court Harp Road Brent Knoll Highbridge Somerset TA9 4HQ Lead Inspector David Kidner Announced Inspection 09:30 7 - 9 December 2005 th th Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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 Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Somerset Court Address Harp Road Brent Knoll Highbridge Somerset TA9 4HQ 01278 760555 01278 760747 doreenpaisley@nas.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) National Autistic Society Mrs Doreen Diana Paisley Care Home 46 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 46 adults in categories LD and PD. Room 4 and 5 of Cadbury Cottage (phase 2) is not to be used without prior consultation with the Commission for Social Care Inspection. 22nd August 2005 Date of last inspection Brief Description of the Service: Somerset Court is registered to provide care for up to 46 people who have a learning difficulty. The home specialises in providing a service to people who have autistic spectrum disorder. Accommodation is arranged in 7 separate accommodation areas with each service user having their own bedroom. Somerset Court is located in a rural location outside the village of Mark, near Burnham-on-Sea. There are no amenities within walking distance but the home provides transport to enable service users to access local facilities. The National Autistic Society owns the home. There is a vacancy for a Registered Manager. The Commission for Social Care Inspection (CSCI) has had discussions with Dianne Rawlings, Area Manager, as to the management action that has been taken in support of the home. Dianne Rawlings is taking overall management of the service until the vacancy is filled. The CSCI are in support of these plans and is in regular contact with the service. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors conducted the Announced Inspection over three days. The Inspectors would like to thank the service users, Senior Managers and the staff team for making the Inspectors welcome at the home and for their contribution to the inspection process. At the time of the Inspection the home still had a vacancy for the Registered Manager. Ms Diane Rawlings, Area Manager is still responsible for the management of the home. The Commission for Social Care Inspection (CSCI) have been kept informed over the major consultation event at Somerset Court. Somerset Court has a Modernisation Programme and is being delivered in three stages. Service users, relatives and all staff have been consulted and are involved in discussions in relation to the future development of Somerset Court. The Inspectors have been advised that Stage 2 has been completed and the final stage of the consultation process is underway. However, it is anticipated that the CSCI will receive applications for 5 Registered Managers, as the management arrangements are such that each accommodation area will have a Registered Manager. This will mean that each accommodation area will become a separate registered service and therefore when registered will receive independent inspections. This is fully supported by the CSCI. Full details of the Modernisation Programme can be obtained from the home. At the time of the Inspection 44 service users were living at the home. The Inspectors visited all of the seven bungalows, viewed records in relation to care and support plans, staff recruitment, health and safety and medicines records. The Inspectors were able to have interaction with a small number of service users. Sixteen staff were spoken to in private and in small group settings. As part of the Inspection process the CSCI requested that he home distributed Relatives/Carers questionnaires. The CSCI was pleased to receive a total on 37 replies. This is an excellent response. The vast majority of responses were very positive. Some relatives were concerned about the numbers of staff on duty at certain times of the week. This was discussed with Diane Rawlings. However, all 37 replies concluded that they are overall happy with the services that their relative receives. The Inspectors also received a number of service user comment cards. The vast majority of the comments were very positive. Service users commented that they have choices, liked the food and staff. It is expected that a number of issues that have been raised and discussed at this Inspection will be addressed when Registered managers have been appointed and in role. As a result of this inspection the home has one requirement and seven recommendations. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that when individual service user’s support guidelines are reviewed that the date is entered when the review took place. The home should review the processes for the recording of service users finances and consider two staff signing for all transactions and that a separate record is kept of the balance of the Building Society. The home should ensure that when risk assessments are reviewed that up to date copies are made available to all staff and located in appropriate files. The home should ensure that the insulin fridge thermostat is set between 2C and 8C. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 7 The home should ensure that in one identified area that this remains accommodation for nine service users and the vacant room is not used. The home should replace the shower curtain and pole in one identified area and ensure that a high clean is conducted in the showering/bathing areas as identified at the inspection. The home should continue to review staffing levels in each area, in particular at weekends, to ensure that service users have adequate support and are able to partake in activities/social events in the evening and at weekends. 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. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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 Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed, as there have not been any admissions to the home since the last inspection. EVIDENCE: Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 On the whole care plans are very detailed and contain all appropriate documentation. However, the home should ensure that the documents relating to changes in care plans and risk assessments are located and stored appropriately. The financial transactions performed by staff on service user’s behalf are not robust. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 11 EVIDENCE: The Inspectors viewed the care plans of five service users. The care plans were very detailed and contained an autistic profile, information on domestic and personal care needs, likes and dislikes and behavioural support plans where needed. Those viewed had been signed, dated and reviewed. Some care plans were more easily to access than others. Some care plans contained very informative pen profiles of service users. This is very helpful for newly appointed or agency staff. The Inspectors discussed the management of service user’s finances. All service users have an individual building society with the exception of two service users whose finances are managed by their relatives. The Inspectors viewed a clear audit trail. Each service user has their finances managed and individual records kept on their behalf. The Inspectors viewed the recording systems that are maintained for individual service users. It was noted that only one staff signature is recorded for financial transactions. It is recommended that the home ensure that two staff sign the transaction records wherever possible to confirm the transaction and balance held for each service user. It is also recommended that the financial transaction forms indicate the actual balance held at the building society. The Inspectors also noted two errors in two recording sheets. These were investigated at the time of the inspection and were satisfactorily resolved. The Inspectors noted that the mealtime guidelines for one service user were dated 2003. The Inspectors were advised that the guidelines were still current. It is recommended that the guidelines should be signed and includes a date when these have been reviewed. Each person has a link book where all staff; including day care, staff note daily records of significant events and behaviour. Key-workers write a monthly summary, which is kept in care plans and gives details of any changes through the previous month. Risk assessments are conducted as and when needed. Individual risk assessments are located in service users files. In some areas there are copies of all service users risk assessments located in one file for ease of access. It was noted that for one service user the risk assessment for the use of transport was different in both files. This was discussed with Diane Rawlings. It is recommended that when risk assessments are reviewed that the home ensures that both files have updated copies. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 Somerset Court offers service users the opportunity to fulfil there spiritual needs if so wished. EVIDENCE: Somerset Court offers a variety of day service activities that service users can access both on site and in other community based facilities in the Burnham area. The Inspectors were advised that a number of service users are also accessing college based activities and are fully supported by staff. Service users have access to a variety of religious denominations and will be supported by staff to attend if so wished. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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): 19 20 21 The home has policies and procedures for the storage and administration of medicines. Following this inspection the home should ensure that good practice is maintained. The home has detailed policies and procedures in relation to bereavement matters. The Inspectors are impressed at the lengths the home goes to in supporting service users through the bereavement process. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 14 EVIDENCE: Service users are registered with local GPs and other healthcare professionals appropriate to their needs. Medical appointments are recorded and these show that service users are accessing a wide range of healthcare professionals including dentists, chiropodists, opticians and physiotherapy. However, the Inspectors noted that records relating to the recording of one service user’s health care needs in relation to a medical appointment and specific needs did not appear to be reported correctly. This was discussed with Diane Rawlings and a Residential Manager at the time of the inspection. This must be addressed to ensure that the service users health care needs are clear and concise and are recorded correctly. Documentation was viewed in relation to support from a Consultant Psychiatrist and Psychology Services. Somerset Court uses the Monitored Dosage System. Medication is stored in individual houses. The Inspectors sampled the medication administration records in all areas of accommodation. They were all satisfactory. Photographs of service users are now in located in the MAR files. It was noted that the minimum/maximum settings for the fridge thermostat were incorrect. The home should ensure that these are set between 2C and 8C. Somerset Court has detailed policies and procedures in relation to death and bereavement. Such policies are entitled: Bereavement Policies and Procedures, Death of a Service User and Informing Service Users of Bereavement and Procedures. There has not been a death at the home for a number of years. The Inspectors were advised of the recent support that the home gave to service users whose family member had recently died. The Inspectors were impressed with the support that the home had given to the service users following the bereavement and supporting the service users to attend the funeral. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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 The home operates a comprehensive Complaints Procedure and ensures that service users are safeguarded from abuse, neglect and self-harm. EVIDENCE: The home has a comprehensive Complaints Policy. There have been no complaints since the last inspection. The CSCI has been kept informed where needed of complaints when they have arisen. Somerset Court has policies and procedures in respect of recognising and reporting abuse and whistle blowing. All staff receive training in the protection of vulnerable adults. SCIP (Strategies for Crisis Intervention and Prevention) is used at the home. SCIP is designed to help and support staff deal safely with aggression and self-injurious behaviours that may occur during a crisis period. Staff must only use the SCIP techniques that are recorded in care plans and only once they have been trained in its use. All staff receive this training during their induction period. The Inspector saw evidence that all staff are checked against the Protection Of Vulnerable Adults list before commencing work at the home. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 30 Not all standards were assessed in each of the accommodation areas. Bedrooms were very well presented and reflected personal preferences and need. The bathrooms and shower room in one area did not appear clean and well maintained. EVIDENCE: The Inspectors viewed all living areas at Somerset Court. Those areas viewed were homely and comfortable. Some areas have been redecorated and recarpeted since the last inspection and new furniture and soft furnishing have been provided. The Inspectors discussed the recommendation made at the last inspection in relation to adequate ventilation in one accommodation area as windows were closed due to one service user accessing the home without being invited. The home has fitted window restrictors but these have been unsuccessful. Diane Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 17 Rawlings confirmed that new behaviour approaches are being explored and assistance from a psychologist is being obtained. The CSCI will monitor this. The Inspectors viewed a number of bedrooms in each accommodation. Bedrooms were very well presented and reflected individual preferences and lifestyles. They were furnished with personal possessions, family photographs, communication aids (STC) TV, Hi-Fi, DVD players. Adaptations have been made to the bedroom environment where needed, to suit individual needs. Each accommodation area has adequate toilet and bathing facilities. However, there is a need to address the number of separate toilet facilities in one area as this can pose problems if the bathroom areas are being occupied. Diane Rawlings confirmed that each accommodation area would be reviewed as part of the Modernisation Plan to ensure that appropriate facilities are provided. The CSCI will be involved in discussions relating to environmental improvements when appropriate. Overall there is adequate communal space at the home. An extension is due to be built in one accommodation. It is the inspector’s opinion that in one identified accommodation that this area remains accommodation for nine service users and the vacant room is not used. All areas viewed appeared clean and hygienic at the time of the inspection. However, the Inspectors recommended that the bathroom areas in one accommodation receive a high clean and that a new shower pole and shower curtain is purchased for the shower room. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 36 Somerset Court is committed to provide staff with a quality Induction and Training and Development programme. The home strives to ensure that service users are supported by an effective team with sufficient number of staff at all times, however the home needs to continue to regularly review its staffing levels. The home has a robust recruitment process. All staff are not receiving regular supervision. EVIDENCE: Staff receive training in specific areas to meet the needs of the service users they support. Such training includes Somerset Total Communication (STC), epilepsy, diabetic training, Strategies for Crisis Intervention and Prevention (SCIP). SCIP is designed to help and support staff deal safely with aggression and self-injurious behaviours that may occur during a crisis period. The National Autistic Society has an NVQ report. Somerset Court currently has 28 staff that have an NVQ3 qualification and there are 14 staff undertaking this qualification. 4 staff hold an NVQ4 qualification. The home is pro-active in this Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 19 area and encourages staff to undertake this qualification. Some staff that the Inspectors spoke to were eager to be nominated to commence their NVQ qualification. The home strives to ensure that service users are supported by an effective team with sufficient number of staff at all times. However, following this inspection there is a recommendation that the home continues to review staffing levels in each area, in particular at weekends, to ensure that service users have adequate support and are able to partake in activities/social events in the evening and at weekends. At the last inspection it was recommended that the staffing levels in one accommodation area be regularly reviewed to ensure there was more than minimum staffing levels available. The home had addressed this and staff stated that this had been very beneficial to the service users and the staff team. The home continues to monitor this. The Inspectors viewed a number of files of recently appointed staff. All files contained the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. Somerset Court has a Training Co-ordinator and he has developed a comprehensive Induction and Training and Development Programme. The home keeps records of all individual staff training. A training audit has been conducted for January to November 2005. The Inspectors received a copy of this audit and the training delivered included Protection of Vulnerable Adults (POVA) (70 staff), Induction training (17 staff), Manual Handling (24 staff), Epilepsy (47 staff), First Aid (49 staff), Managing Performance (06 staff), Appraisal Briefing (18 staff) and COSHH (13 staff). The Training and Development Plan now includes a Registered Managers Training Programme for 2005/6. The Inspector spoke to a number of staff in relation to receiving regular supervision. It was noted that staff are receiving more regular supervision in some areas more so than others. The home should ensure that all staff receive regular supervision. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 42 Whilst there is a vacancy for a Registered Manager the home is being very well managed by the Area Manager. Somerset Court is very pro-active in promoting health and safety at the home. However, it must address the need to ensure that all staff receive regular fire training. EVIDENCE: It was evident that Diane Rawlings has made every effort to keep service users, relatives and staff informed of the Modernisation Plans. Service users and parents/relatives have been widely consulted and documentation to the outcomes has been produced. The CSCI has not received any complaints or concerns in relation to the modernisation plans. It appears that the management approach of the home is open, positive and inclusive. The CSCI has not received any complaints or concerns from any source in relation to the modernisation plans. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 21 The Inspectors spoke at length with Diane Rawlings and were supplied with documentation that has been disseminated to staff to keep them informed. The Inspectors spoke to a number of staff in relation to their understanding of the consultation/information process and the future plans for Somerset Court. Some staff stated that they had not received detailed information in relation to the Modernisation Plans and appeared uncertain about the future. It is the Inspectors opinion that staff may have received different information at different times by different Residential Managers that may have caused misunderstanding/confusion. Diane Rawlings acknowledged this and will be revisiting this matter. The Inspectors sampled the fire records. Weekly fire checks have been conducted. Monthly checks are conducted on the emergency lights and maintenance records are kept in relation to the torches. A Fire Alarm Certificate for the fire system, emergency lighting and smoke detectors was issued for the site on the 20 May 2005. The Inspectors viewed the records in relation to staff receiving fire training. It was noted that a number of night care workers had not received regular fire training. An Immediate Requirement was issued at the time of the inspection. Records are kept of hot water, fridge and freezer temperatures. The home had an Environmental Health Officers (food hygiene) visit on the 25 May 2005. Staff receive training in health and safety issues including first aid and food hygiene when they begin work at the home and on an ongoing basis. All incidents are recorded and entered onto a computer package, which is able to analyse these and provide valuable information in respect of patterns and frequencies. The Inspectors discussed the recent audit of service user incidents at the home. Somerset Court is very pro-active in making every effort to address incidents and respond accordingly. All accidents are recorded at the home and are audited. Risk assessments are in place in respect of environmental hazards and individual service user risk assessments. Portable appliance testing has been conducted in all accommodation areas. This was an outstanding recommendation. Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 2 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Somerset Court Score X 3 3 4 Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000015975.V261907.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 23 (4) (d) Requirement The home must ensure that arrangements are made for all staff to receive suitable training in fire prevention. Timescale for action 09/12/05 Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA7 Good Practice Recommendations The home should ensure that when individual service user’s support guidelines are reviewed that the date is entered when the review took place. The home should review the processes for the recording of service users finances and consider two staff signing for all transactions and that a separate record is kept of the balance of the Building Society. The home should ensure that when risk assessments are reviewed that up to date copies are made available to all staff and located in appropriate files. The home should ensure that the insulin fridge thermostat is set between 2C and 8C. The home should ensure that in one identified area that this remains accommodation for nine service users and the vacant room is not used. The home should replace the shower curtain and pole in one identified area and ensure that a high clean is conducted in the showering/bathing areas as identified at the inspection. The home should continue to review staffing levels in each area, in particular at weekends, to ensure that service users have adequate support and are able to partake in activities/social events in the evening and at weekends. 3. 4. 5 6 YA9 YA20 YA28 YA30 7 YA33 Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Somerset Court DS0000015975.V261907.R01.S.doc Version 5.0 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. 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