Inspection on 03/10/06 for Overcliff

This inspection was carried out on 3rd October 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 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

Overcliff 08/11/05

Overcliff 20/05/05

Overcliff 07/12/04

Overcliff 14/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Overcliff 329 Babbacombe Road Torquay Devon TQ1 3TB Lead Inspector Sam Sly Unannounced Inspection 3 October 2006 12:30 rd Overcliff DS0000018406.V306019.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 Overcliff DS0000018406.V306019.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. Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overcliff Address 329 Babbacombe Road Torquay Devon TQ1 3TB 01803 292276 01803 200796 Allison@overcliff.wanadoo.co.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) Rotel Ltd Mr Paul Whitehead Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mr Paul Whitehead must attain the qualifications required by CSCI (currently the Registered Manager Award and NVQ 4 in care) within twelve months. 8th November 2005 Date of last inspection Brief Description of the Service: Overcliff is a large house set on a hillside on the Babbacombe road in Torquay. Care is provided for up to twelve residents with Learning Disabilities. Access at the front of the Home is up several flights of steps with some railings to a sun terrace. Access at the back of the Home is through a car parking area and garden, down steps through a patio area. There is a self-contained flat below the home, which is counted as one of the bedrooms. The ground floor of the main house has a dining room, kitchen and lounge with three single bedrooms with wash hand basins, an office, and two sleeping-in rooms for staff, a bathroom and shower room with toilet. Stairs lead to the first floor that comprises of six further single bedrooms with wash hand basins, a double bedroom, a laundry, two bathrooms and a separate toilet. Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and took place during a weekday afternoon in October. It included talking to all but two of the residents during the afternoon. Discussion also took place with the staff on duty and the registered manager Paul Whitehead. The care of three residents was looked at in detail. This included talking to them, talking to staff about their care and looking at records that are kept about them. All types of written records were examined including staff records. A tour of the all shared rooms at Overcliff and some of the bedrooms was carried out. To write this report all the records of contact the Commission has had with Overcliff since the last inspection were looked at. The registered manager provided information too. All the residents, three staff, eleven relatives, and one care manager returned comment cards to the Commission. The weekly fee at Overcliff ranges from £300 - £600, with two residents receiving three hours 1:1 staff support each day. . All the standards that the Commission thinks are most important were looked at during the inspection process. What the service does well: Before a resident moves to Overcliff they are given information to help them make up their minds. Also the care they might need is discussed in detail with them, written done and put on CD so staff know how to support them. Residents are very happy to live at Overcliff. Residents told the Commission: ‘Good place, good home.’ ‘ I am very happy at Overcliff.’ ‘Good home to live in, good crowd, good bunch.’ ‘The home is very nice, and the manager and staff help me, we laugh about lots of things. I go out on Saturdays, go to Bygones, zoo and pub.’ Relatives are very happy with the support provided at Overcliff. Relatives told the Commission: ‘My [relative] seems very happy and well cared for…other residents seem happy and there is a warm loving atmosphere that treats all residents with dignity.’ Staff like working at Overcliff and think it supports residents well. Staff told the Commission: ‘It treats the service users with respect, dignity and as an Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 6 independent individual and is a lovely place to work in with great staff and lovely residents.’ Residents make many of the major decisions at Overcliff and feel able to express concerns and feel listened to. They lead interesting, useful lives and are out and about in the community Residents are supported in ways they like, by trained, enthusiastic, nice staff and Overcliff is run well by a good manager. . 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. Overcliff DS0000018406.V306019.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 Overcliff DS0000018406.V306019.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 the service. Residents are given enough information to choose whether to live at Overcliff, and their needs are assessed thoroughly before they move in. EVIDENCE: Residents that returned comment cards to the Commission all said they chose to move to Overcliff and were given information about the Home before moving in. Residents said: ‘I chose to move to Overcliff myself’, ‘I am very happy here’, ‘I like it here.’ One resident spoken with said she had a trial stay and visits before moving in. The information about Overcliff that is given to residents (the Service User Guide) and to other people (the Statement of Purpose) is up-to-date and written in easy to read language. Three residents care planning was looked at. The most recently admitted resident’s information was not at Overcliff on the day of the visit, but was looked at later. It was very detailed, and discussion with the resident found that she had been involved with making her plan, and knew what had been written down. The two other resident’s plans that were looked at were based on detailed assessments, including information given by the care managers before admission. Overcliff DS0000018406.V306019.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 good. This judgement has been made using available evidence including a visit to the service. Decision-making and risk taking is a major part of life at Overcliff, with individual care plans reflecting resident’s goals and aspirations. EVIDENCE: Three resident’s care planning was looked at and staff and residents were spoken with. Residents said they were involved in deciding what care they received, and signed to say they agreed with the plan. Regular reviews were held within the home through key worker meetings and meetings with the manager and the care plan is on a compact disc (CD) so residents can view their plan at anytime. Reviews were also held with care managers regularly. Care plans were set out in a clear, easy to read format and reflected what residents said happened at Overcliff. Risks were also discussed with residents, and plans made and recorded to make sure risks did not stop them doing what they wanted to. During the site visit the manager and one resident talked about the goals the resident wanted to reach and steps that were being taken to reach these goals in the future. Two residents received one-to-one staff support for a few hours a day and this Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 10 support was being adequately provided to enable the residents to access the community safely. One resident spoken to is always supported by staff when out in the community, this is part of the residents risk assessment, and could be seen as a restriction on her freedom, however discussion with the resident found that she was clear about why she was supported, and the registered manager was working with her towards a goal of being more independent. A behavioural plan was in use for one resident, with a policy and guidance for staff. This plan clearly stated the restrictions in place and included clear guidance on the use of ‘as required’ (PRN) medication. All residents that were spoken to, or sent comment cards to the Commission said they make their own decisions about what they want to do every day. Also the registered manager and staff go to great lengths to put all the decisions about the home into the hands of the residents. Resident meeting records showed meetings were well attended and views were listened to and acted on. Discussion took place about meals, activities and anything else anyone wanted to talk about. The registered manager or a senior staff member also had regular one-to-one meetings with residents to make sure they were happy with their key worker and did not have any worries. The key worker also held regular meetings with their allocated residents. One resident had written a questionnaire that was used for potential new staff as part of the interview process, and staff were always introduced to residents as part of the interview and their views formed part of the decision-making process. The registered provider and staff handled most resident’s finances, although everyone handled their cash, and a few went to the bank to withdraw cash. When asked, all the residents spoken to said this was their choice. Detailed records were kept of receipts, bank balances and cash held in the home, and this was audited by the registered manager regularly. A company director was Department of Work & Pensions appointee for many of the residents. There were clear records in each residents care plan to show them what benefits they were receiving. Overcliff DS0000018406.V306019.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, 14, 15 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. Residents not only lead interesting active stimulating lives at Overcliff, but they gain in confidence and independence too. EVIDENCE: Overcliff excels at ensuring residents do the things they want to do with their lives, and at making sure they actively participate in the local community. Residents spoken with all did activities including work, education and more traditional segregated day services for people with learning disabilities. Those at day services run by Rotel (the Owners of Overcliff) and the local authority did so because they wanted to, and one resident said: ‘I don’t want to go to day care sometimes so I do not go.’ The registered manager supported this. The registered manager had made links with a service that helps to find work for people with learning disabilities and two residents have job placements, which they value. Another resident was about to be referred. Two residents are members of a local self-advocacy group and regularly attend meetings Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 12 locally and around the Country. Residents say they do lots and lots of activities both at Overcliff and in the local community. Residents who returned comment cards to the Commission said: ‘My days and nights are fully packed with lots of things to do.’ ‘Sometimes I see my mum at the weekend.’ ‘On Saturdays I walk into town to go shopping.’ ‘CRC weekdays, bingo, pub, exercise, cooking night time, go out, walks, Bygones, zoo at weekends.’ Residents plan and go on an annual holiday, and family contact is encouraged and supported. Comments received by the Commission from relatives said: ‘my [relative] seems very happy and well cared for. Other residents seem happy and there is a warm loving atmosphere that treats all residents with dignity.’ ‘Overcliff has given good care and support to our [relative]. Overall we are satisfied with the care.’ Daily routines revolve around what residents want to do, and need to do. All but two residents have single bedrooms. The two residents that share do so through choice. During the visit staff were interacting with residents at all times, although one staff member’s understand and use of English was not good, which made communication difficult at times. However, the residents liked the staff member and the registered manager had identified some English language lessons for him to attend. The registered manager had recently got all the residents free bus passes and an accompany pass for staff members. This meant residents were able to use public transport. The registered manager was also actively challenging an equality barrier on behalf of residents as the bus company only allow a staff member to accompany an identified resident, which restricts them using the buses as much as they would like to. Residents decide menus during their meetings, and they are also involved in some shopping, preparation and clearing away. Every Saturday a different resident chooses a special meal, and residents often eat out, go to the pub or have take away food. Residents also have cooking lessons. Residents said the food was good. Some staff did not have current food hygiene certificates. Overcliff DS0000018406.V306019.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 good. This judgement has been made using available evidence including a visit to the service. The health and personal care support and medication practices provided enable residents to develop independence. EVIDENCE: Residents spoken with said staff support was given in ways they preferred, most support was encouragement and verbal prompting, although more personal care support was now given to some of the older residents. The care manager who returned a comment card to the Commission said that staff understood resident’s needs, followed a care plan, notified them of significant events affecting residents welfare and said they were satisfied with the overall care provided. Records are kept of all health related meetings and appointments, and inform the residents risk assessment and care plan. The staff showed that they were dealing with a range of health related issues sensitively, confidentially and with compassion. All residents are registered with local GP’s and receive regular health checks including dentist, hearing and sight examinations. None of the residents self-administered medication, although a risk assessment was in place to develop this practice. Residents spoken with said Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 14 they preferred staff looking after their medication. Medication procedures for staff administration of drugs were observed. Medication was kept in a secure metal cupboard, with controlled drugs stored in appropriately. Records were kept of medication administered, and administered controlled drugs were recorded in a special register. The receipt and disposal of medication was carried out properly and a pharmacist regularly monitors the procedures at Overcliff. Overcliff DS0000018406.V306019.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 the service. Staff listen to resident concerns and act on them and residents are protected from abuse. EVIDENCE: It was evident through the records seen, comment cards received by the Commission and through discussion with staff and residents that residents feel confident about discussing concerns with staff, and that concerns are dealt with swiftly and appropriately before they turn into complaints. Residents are given many different ways to express concerns; group meetings, one-to-one meetings, questionnaires through the registered manager and through the Company, meetings with other residents within the Company’s homes and through a formal complaints procedure that is in an accessible format. Residents were absolutely clear about whom to go to with a complaint, and gave a wide range of people they felt able to go to if unhappy including family, staff, the registered manager and the Responsible Individual for the Company. However, of the two relatives who returned comment cards to the Commission one was not aware of the Home’s complaints procedure, so it is recommended that relatives are reminded of the process. Neither the Commission nor the Home has received any formal complaints since the last inspection. Staff had attended adult protection training, and there was lots of information including the local authority Alerter’s Guidance and department of health guidance ‘No secrets’ Guidance for staff. There was also lots of information Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 16 available on positive behavioural management, including good practice advice from the British Institute for Learning Disabilities (BILD). This good practice was reflected in the behavioural plan developed by staff for one of the residents at Overcliff. Staff interviewed were aware of adult protection procedures, the complaints procedure and the whistle blowing procedure. Overcliff DS0000018406.V306019.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 adequate. This judgement has been made using available evidence including a visit to the service. Overcliff is homely, safe, clean and comfortable but the maintenance system does not sustain improvement. EVIDENCE: The premises at Overcliff are clean, with a cleaner employed and residents encouraged and supported to do laundry and keep their bedrooms tidy and clean. A resident who returned a comment card said: ‘I am happy the home is clean.’ There were several maintenance issues identified during the visit: A resident commented that ‘the bathroom near my bedroom needs painting’. This bathroom had suffered water damage and was waiting for re-painting and possible re-plastering. One resident also thought that new dining room furniture was needed, this furniture was seen to be worn and not matching. Replacing this furniture had been recommended to the registered provider at inspections in the past. The entrance path was uneven and could cause a slip hazard, the cupboard containing toxic cleaning products was broken and could not be locked, the flooring in several of the toilets was discoloured and needed replacing, wall paper on the ceiling of one bedroom was pealing off, there was a bucket for cigarette ends on the fire escape, which could be a trip hazard, and the hallway carpet was fraying on the stairs, again a potential trip hazard. Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 18 The Company’s maintenance team dealt with maintenance issues on an immediate, six monthly or twelve monthly basis however, it was clear that longer term six monthly and twelve monthly jobs were less likely to get done, and there was no timescales to indicate for example when six months or twelve months had passed by. The laundry facilities were clean and hygienic, with staff receiving infection control training. Overcliff DS0000018406.V306019.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, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported by a dedicated, enthusiastic, competent and effective staff team, and are protected by the staff recruitment process. EVIDENCE: The staff team at Overcliff is small (four staff, a registered manager and a cleaner/care staff), but there was no evidence that this reduced the quality of life for residents. There were two care staff on at all times, and additional staff to provide three hours one-to-one support to two residents. Residents spoken with, and who returned comment cards said: ‘Good staff, very good we can have a good laugh, good food’ and ‘I like the staff at Overcliff’. Staff were accessible and approachable and all residents said they would go to the registered manager, staff or their key worker if they were unhappy. Staff spoken to have done a range of training, both about care and about learning disabilities, and all staff were doing, or had completed NVQ training. Staff were well supported with regular supervision and personal development meetings. There were also regular staff team meetings. Staff who returned comment cards to the Commission indicated that the recruitment process was sound, that adult protection was understood, and that they felt supported by the registered manager. Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 20 Two staff files were examined and a thorough recruitment process had been followed and sufficient fitness checks, including CRB checks had been carried out. There was no written interview record in either staff file, indicating that decision-making about staff fitness was not being recorded. Overcliff DS0000018406.V306019.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 good. This judgement has been made using available evidence including a visit to the service. The quality of care at Overcliff is starting to be monitored by the Owners, and residents benefit from a well run home. EVIDENCE: The registered manager said that he had finished the NVQ 4 and Registered Manager Award and was awaiting Certificates. He had also attended training including supervisory skills and other courses that the staff had attended in the last year to maintain his skills and expertise. Staff and residents spoke highly of the registered manager. Residents said they would go to him if they were unhappy, and one staff member said he was ‘open and easy to talk to and a good laugh.’ The registered manager regularly attended meeting for the managers of the Company. The Responsible Individual Alison Whitehead has developed a Quality Assurance system including questionnaires, which have been sent out to relatives, residents, staff and professionals. This information is in the process Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 22 of being collated, but as yet no annual development plan has been written based on the findings of these questionnaires and the other quality monitoring processes. The monthly monitoring visits to Overcliff by the registered provider stopped earlier this year, and should start up again. The Commission received comments back from staff that they felt an improvement to the care provided at Overcliff would be ‘more involvement and support from the Company (Rotel)’ and staff felt Company decisions were imposed without staff being asked or consulted. These comments are reflective of comments with regard to another of the Companies care homes. The pre-inspection questionnaire returned to the Commission by the registered manager shows that regular health & safety checks are carried out at Overcliff on the prevention of Legionella, gas, electrics, and COSHH. During the visit the cupboard storing toxic cleaning products was found to be broken, so could not be locked as required. The fire records were accurate and up to date, with a resident helping a staff member with these checks. Accidents were also recorded properly. Most, but not all staff had received training on basic health & safety, moving and handling, fire safety, first aid, infection control and food hygiene. The staff member interviewed required first aid and food hygiene training. Overcliff DS0000018406.V306019.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Overcliff DS0000018406.V306019.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA39 Regulation 26 Requirement The registered provider must ensure that monthly visits are made to Overcliff. Timescale for action 05/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. 4. 5. 6. 7. Overcliff Refer to Standard YA22 YA24 YA34 YA35 YA35 YA37 YA39 Good Practice Recommendations The registered manager should ensure that relatives of residents are clear about the complaints procedure. The maintenance issues identified in this report should be acted on swiftly. A written interview format should be used during staff recruitment to record decision-making. There should be an overall staff team training plan so that the registered manager is aware what training has been completed and is required. All staff handling food should have Food hygiene certificates. Copies of the registered manager’s Registered Manager Award and NVQ 4 should be forwarded to the Commission when received. The Quality Assurance system should result in an annual DS0000018406.V306019.R01.S.doc Version 5.2 Page 25 8. 9. YA42 YA43 development plan and feedback to participants. The COSHH cupboard should be replaced. The registered provider should ensure staff concerns about consultation and more Director involvement and support are investigated and action taken. 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