Inspection on 16/07/08 for Sailaway Residential Home

This inspection was carried out on 16th July 2008.

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

The inspector 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

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Sailaway Residential Home Main Road Bosham Chichester West Sussex PO18 8PH Lead Inspector Val Sevier Unannounced Inspection 10:00a 16th July 2008 X10015.doc Version 1.40 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 Sailaway Residential Home DS0000071031.V367347.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 Older People. 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. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sailaway Residential Home Address Main Road Bosham Chichester West Sussex PO18 8PH 01243 572556 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) Mrs Saroj Dahiya Manager post vacant Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 18. Date of last inspection N/A new service Brief Description of the Service: Sailaway is a care establishment registered to provide accommodation for up to 18 individuals, in the category OP (old age not falling in any other category). The establishment is situated on the main road near the village of Bosham. Local bus routes to Chichester are near by. Accommodation is provided on ground and first floor level. There is a chair lift to the first floor. All rooms are generally for single occupancy however there are two rooms that can be used as doubles providing the occupancy levels do not exceed 18. The service is privately owned. The proprietor is Mrs Saroj Dahiya. The current fees range from £330 to £420, which is dependent on whether the individual is privately funded or social service and the size of the room. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 1 star. This means the people that use this service experience adequate quality outcomes. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 16th July 2008, during which we were able to have discussions with staff and have interaction with people who use the service. This was the first visit to this service following a change in ownership. During the visit we looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and people at the home, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. We received 9 surveys: from individuals living at the home and on the day of the visit we were also able to speak with three relatives who were visiting. At the time of writing this report we had not received back any surveys that had been sent to staff and other professionals. The home does not currently have a registered manager, the registered provider Mrs Saroj Dahiya, is working towards her NVQ 4 in care after which she intends to apply to be registered as the manager. Mrs Dahiya is working at the home as the manager and being supported to do this by the previous owner the staff and her family. When we arrived we were informed that the registered owner Mrs Dahiya had just left having been on duty overnight at the home. We spoke with her on the phone and offered the choice of returning to participate in the visit Mrs Dahiya chose to return. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and look at the facilities of the home. The manager seeks information from external healthcare professionals as part of Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 6 the assessment where necessary, to ensure that the home is able to meet assessed needs. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Daily routines in the home were flexible and people who use the service being encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. People who live at the home were positive about the food that the home provided and were pleased with the activities in which they could participate and the condition of the accommodation that they occupied. People at the home, relatives and staff had confidence in the effectiveness of the home’s owner. Where systems and procedures were in place in the home they worked well including, dealing with complaints, quality monitoring, and health and safety. What has improved since the last inspection? What they could do better: Care plans must detail the care and support needs for individuals where support has been identified so that staff are aware what they need to do for people who live at the home. Risk assessments must be reviewed to take into account individual’s capacity and understanding of the homes policies to promote individual dignity. There must be a policy for the giving of medication, which must be administered safely. An assessment for individuals who wish to look after and administer their own medication must be in place. The procedure for recruiting staff must ensure that there are CRB, POVA first and references before employment commences, to protect those people that live at the home. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process, which involves others as needed. The statement of purpose and service users guide is informative however; it needs amending to reflect the commission’s new contact details. EVIDENCE: We received the AQAA for the home, which stated that: “At our home we aim to provide a comfortable, safe and familiar environment. Prospective residents and their families are provided with the relevant information they need to make an informed choice about the home and are encouraged to visit the home before deciding if we provide the right environment for them. This initial visit allows us to assess the potential resident to ensure we are able to fully Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 10 cater for their needs. The resident’s requirements are documented so that we can ensure residents independence in maintained. We have a Statement of Purpose and Service User Guide, which describe the aims and objectives of the home and the facilities available. This document is offered to the residents and their relatives to help them make a choice where the prospective resident wants to live. The prospective resident and relatives are shown around, introduced to staff and residents and are invited to look at vacant rooms. This allows freedom of choice”. We looked at the statement of purpose and service users guide, two people who have recently moved to the home said that they had been given copies of these documents to look at and these were seen on their rooms. The documents have the previous contact details for the commission, and this was discussed with the owner. There was also discussion regarding the inclusion of the name of the previous owner who is supporting Mrs Dahiya. The AQAA was supported by evidence in the records at the home and with talking with a relative of an individual who had moved to the home in the last six months. The assessment includes the following areas: a contact names sheet, personal details, medical details for example doctor and health issues; social information for example previous occupation, children and social history; allergies; next of kin. This information is also included on another assessment sheet with larger spaces to write and includes medication. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The records and systems within the home do not always ensure that the personal and healthcare needs of people who use the service are met safely and effectively. Staff working practice helped to ensure that the privacy and dignity of people who use the service is promoted. EVIDENCE: The home’s AQAA told us that: “In regards to health and personal care we feel that we do the following well: Encourage and respect the privacy of our residents, Maintenance and reviews of care plans, Records to monitor healthcare needs of residents. Each resident is acknowledged in a dignified manner. Where appropriate, we follow their personal requests in regards to their healthcare and wishes at the time of death. All staff are aware of the need to be sensitive and confidential in regards to residents personal issues. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 12 We conduct a pre-admission assessment on all of our residents, upon their arrival another assessment is carried out. In both assessments the residents and families are involved fully. All residents have a care plan which has been developed from their needs assessment. The plans are updated regularly to ensure that the right level of care is provided for the changing needs of the resident. “ We sampled three care plans of people who use the service that had moved to the home in the last year. The care plans sampled were being used in conjunction with medication records and other health-monitoring tools that are used as part of the care planning for individuals. The care plans are written on one piece of paper the first side is a repeat of information seen on the pre admission assessment and includes next of kin details, name, previous address and GP. On side two it states “An assessment should be made of the clients ability to organise himself or herself with regards to the following”. There follows several boxes for completion including getting up alone, orientation, social behaviour, planning the day religious and cultural needs – these two boxes were not completed for any of the care plans seen. One individual’s care plan gave information for staff that the individual “needs some assistance”. This was in relation to getting up. There was no information on how or what assistance staff should give, this lack of detail and information was noted on other plans seen. It was seen that for one individual who smokes it was on their risk assessment, the individual has to ask staff for their cigarettes when they want them. This was discussed with both the deputy manager and registered provider with regards to capacity and risk. This individual had a fall on the 18th March outside with other people who live at the home; the Gp was called on the 22nd May following complaints of pain. Walking is noted on the risk assessment. There is a daily report kept for individuals, which is completed as needed, and not on a daily basis. It was seen that events such as visitors, chiropody and hairdressing are noted in the homes diary. The last dates for the daily records for the individual care plans seen were 2nd, 3rd and 4th July 2008. There was a care plan monthly review form where there was space for objectives to be reviewed. For one individual the review form noted personal care, mobility and medication however this did not correspond with the care plan action for staff. This review was dated 23rd February 2008. A second care plan had been reviewed in April 2008 with a review date of May 2008 there was no evidence that this review had happened. The care plan for this individual advised staff to “observe weight changes”, a weight record was seen with the last date being 17th January 2008. This care plan advised staff to Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 13 for example, “Provide assistance when necessary, maintain independence, ensure they know location and use of call bell” and “to promote orientation offer reassurance and encouragement”. It was seen that there is input from health professionals as needed, a district nurse calls to carry out blood tests for individuals with diabetes, and for those on Warfarin, also it was noted that the district nurse had been visiting to carry out dressings. Eye tests have been booked for individuals were requested; a chiropodist calls every six weeks. The home had written policies and procedures concerned with the management and administration of medication. We saw one, dated 2004 on the outside of the cupboard where the medication is kept. The registered provider said that she had re written the policy in light of some issues she had found with medication. The medication is kept in a metal cupboard in the kitchen. The medication is delivered by the chemist in a blister pack with Medication Administration Record sheets (MAR). It was seen that one individual had been without their Adcal for three days as it was not available, between the 30/6/08 and 3/07/08 although it had been signed for on the morning of the 2/07/08 it was recorded as not available in the pm of that day. One individual self-administers three types of eye drops, whilst the home administers other medication for this individual. We did not see an assessment for self-administering medication. We saw a box with pots with what seemed to be film pots, with individual names on them, we asked staff what they were used for they told us that morning medication was taken from the blister pack and put in these pots, which were then put on the breakfast trays. We discussed this with the registered provider who said that this was one of the practice issues that she was trying to stop. Mrs Dahiya said that she has booked medication training for staff for August 2008. Staff were observed speaking and assisting individuals with dignity and respect. It had been seen on care plans that the preferred choice of name had been recorded and staff were heard to speak to individuals by the name they wished. People we spoke with at the home had high praise for the staff and management saying that nothing was too much for them and that they felt well cared for. Relatives of those that live at the home also spoke highly of the staff and the care they see is given, and would recommend the home to anyone. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service participate in some activities appropriate to their age, peer group and cultural beliefs and as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: The AQAA for the home told us that “We feel that we do the following well: The routines of the home are planned around the residents. A variety of activities are provided. Social contact in encouraged with family members and friends. A high standard of home cooked food is provided with alternatives available”. In what they could do better the homes stated:” Improvements could be made in arranging more outings for the residents including trips to local shopping centres and places of interest”. The registered provider said that she was planning to take three or four people out each week to a local area. We found that the home has several areas to sit in, the lounge, conservatory, dining area and outside under a gazebo. The dining room had a bookcase with Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 15 a variety of books and a notice to stay that the mobile library would be calling on the 23rd July 2008 to change the books. It was seen in receipts and in the diary that individuals at the home receive newspapers. We looked at the activity records and noted that the last record of any activity was 26/01/2008. We asked staff where they recorded activities they said in that file. We looked in the diary and saw that there is Tai Chi every fortnight staff said four people participate regularly with that. We also saw that there is reflexology fortnightly. A singing group comes to the home the last time was June 2008 they are due in August 2008. Music for health came to the home in April 2008. We asked staff what activities were arranged for the day we were there we were told it was a quiet day. Staff carry out activities usually in the afternoon and these can be skittles, bingo, quizzes and games. One individual went out for lunch with their family on the day of the visit. The home operates an open visiting policy and maintains family ties. People living at the home are encouraged to exercise control over their lives and it is their choice to participate in social activities if they wish. Visitors spoken with said that staff try to help the people living at the home to maintain their rights and for them to be able to make informed choices around daily living. One individual has asked and is enabled to lay the tables for meals. They said they enjoy being helpful and it gives them something to do. People who use the service who passed comment on the day were complimentary about the food provided. The meals seen looked nice and were presented in a way that looked appealing. The lunch on the day was roast chicken roast potatoes and vegetables there were several sweets for people to choose from. We looked at the diary and saw that there is a record of breakfast and the main meal of the day another book is kept for suppers. It was seen that the day before there was a range of meals that had been given; ham sandwiches, scrambled eggs, toast and pate, salad and mandarins and ice cream. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of safeguarding and protection issues. EVIDENCE: The homes complaints procedure was seen to be available in the information given to people who use the service. There have been no complaints received by the commission. The registered provider said that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses West Sussex safeguarding adult policy and staff were seen to have had training in adult protection. The home’s AQAA stated that” At Sailaway Residential Care Home we include a copy of the complaints procedure with the service user guide. The complaints procedure is also displayed in the entrance hall. It is clear and gives assurance that the complaints will be dealt with within 28 days. We also make sure that all service users and relatives are made to feel confident that their complaints will be listened to, taken seriously and acted upon. All members of staff are aware of the complaints procedures. Action is taken immediately if there are any signs of abuse. All new staff will only be appointed when they have Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 17 provided evidence of the qualifications need to work with vulnerable adults and have satisfied police checks”. It was noted that the complaints policy needed to have the commission’s contact details changed the provider was advised of this. People who use the service and their representatives have commented in the surveys we received and on the day when we spoke with them, that the home staff are approachable and that they feel listened to. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service in the main have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: We looked around some of the home and we were able to see communal areas such as the dining room, lounge, bedrooms and bathrooms. The garden is accessible with wheelchairs. People who live at the home are encouraged to furnish the room with personal belongings such as furniture and pictures, to make it feel like home. The provider is new to the home and has begun to redecorate and make changes. Mrs Dahiya said that she has redecorated the lounge and dining room buying new furniture and curtains. A stair lift has been installed, the grounds Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 19 have been cleared and new plants put in. Mrs Dahiya explained some future plans for decorating bedrooms and bathrooms and for possibly altering a bathroom, which people who use the service do not use, as they feel it is too small. She also plans to put a sitting area/garden at the back of the property enabling another area to be utilised and for people to be able to walk around the home. Some bedrooms on the ground floor at the back of the property were seen to be quite dark despite the sunny day and Mrs Dahiya said these rooms need the light on most of the time, the neighbour was trimming their trees whilst we there and Mrs Dahiya hoped this would help. Some rooms downstairs had a strong malodour. Mrs Dahiya said she would look into this. The care staff carry out the cleaning of the home and the laundry in addition to their caring role. The AQAA for the home told us that: “All doors have been brought up to fire standards regulation. There is regular maintenance of the grounds to allow residence to enjoy the gardens and outside seating. Residents are encouraged to personalise their rooms with photographs, pictures, ornaments and small pieces of furniture to create a familiar environment. Recently a stair-lift has been installed to make it easier for the residents to get around. All staff are responsible for cleaning the home in order to keep it pleasant and hygienic and understand the importance of this”. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have received the mandatory training that is expected each year, however it was not clear that staff have received training to meet all the needs of people who use the service. The lack of checks in the current recruitment process places people who use the service at risk. EVIDENCE: The staffing structure at the home consists of: registered provider, support workers and kitchen staff. We saw the rota and there are two staff on throughout the twenty four hours. Of the two night staff one is awake and one sleeps. We noted that the registered provider was on the rota as care staff on occasions, and had been on night duty the night before our visit. Other health care professionals support the team from outside the home as needed. Staff spoken with on the day of inspection indicated that they were aware of the needs of the people who live at the home. There was evidence that staff have received training in mandatory areas such as food hygiene, first aid and manual handling, health and safety and safeguarding adults. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 21 The AQAA for the home stated that: “Training is provided for all members of staff which allows them the opportunity to maintain and develop their skills. Our recruitment policies ensure the protection of our service user. New staff are only appointed following completion of a satisfactory police check and satisfactory check of the protection of children and vulnerable adults. Each shift consists of a combination of staff with different skills in order to ensure that service users are in safe hands at all times”. We looked at two files of staff that the registered provider had recruited in the last six months. One had an application form only. The registered provider stated that the individual was leaving and she had given them their CRB and POVA. There was no record of any references having been sought. Mrs Dahiya said that she had only been given phone numbers and that she had rung these two people. She was advised that written references must be obtained in addition to keeping notes on any verbal references. The other staff file we saw had an application form, there were no written references, or evidence that the CRB and POVA had been applied for the person was working in maintaining the home. We saw a form, which staff had signed to say that they were not on the POVA list, nor had they committed any criminal offences. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lack of information in the care plans; current medication administration and recruitment practices may place people who use the service at risk. The provider needs to ensure that all systems and procedures are in place, which monitor and maintain the quality of the service provided and which, promote the safety and welfare of those living and working in the home. There need to be sufficient dedicated management hours in the home for this to be achieved. EVIDENCE: There is currently no registered manager for the service. The registered provider Mrs Dahiya stated that she intends to apply to be the registered manager when she has completed her NVQ 4 in care. Mrs Dahiya has worked Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 23 in the care field for over 17 years as a support worked in a variety of services including health. There were a range of written policies and procedures available for staff to refer to as guidance and to inform their practice. These included the following: • Admission, discharge and transfer of residents • Human Rights • Confidentiality and access to personal records • Abuse of the person • Drug administration • Self administration of medication • Infection control • Complaints procedure • Whistle-blowing • Sexuality • Health and safety at work The people who use the service and their relatives or representatives and the staff, are able to discus all aspects of the running of the home generally or on a personal level. This opportunity is offered in resident, relative and staff meetings, and in questionnaires, which are sent out regularly. We saw that the home has a quality assurance tool in place and different areas are looked at usually on a monthly basis. Individual monies and valuables can be locked in lockable boxes in the resident’s room. We sampled some records of individual monies held by the home and found that the money available matched the records and receipts. It was noted that the home’s equipment, plant and systems were checked and serviced or implemented at yearly, or six monthly or as manufacturers require for example; hoists; fire safety equipment portable electrical equipment; and hot water system. There were contracts in place for the disposal of clinical and household waste. Records were kept of accidents. There was a fire risk assessment for the premises; tests of equipment and regular risk assessments of the premises and working practices were undertaken regularly with fire alarms set off weekly and monthly checks of for equipment. Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 15 Sch 3 (1)(b) 13 (4) (b)(c) Requirement People who use the service must have clear individual care plans describing the support that staff give to meet identified needs The home must consider capacity of the individual when looking at risk assessments and policies, to ensure that risks are considered on an individual basis for example smoking. Individuals must be assessed to ensure safety for selfadministration of medication. In the interests of safe medication handling and to show that people who use the service get their medicines as prescribed you must: Give medicines directly from the original labelled container to people and not place medicines into any secondary container for administration by another carer. A thorough recruitment of staff must include references, CRB and POVA First checks to protect people who use the service. Where a verbal reference is DS0000071031.V367347.R01.S.doc Timescale for action 16/10/08 2 OP8 16/10/08 3 4 OP9 OP9 13 (2) 13 (2) 16/08/08 16/08/08 5 OP29 19 Sch 2 (5)(6)(7) 16/08/08 Sailaway Residential Home Version 5.2 Page 26 sought a record of this must be kept and followed up with a written reference from the referee. 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 Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sailaway Residential Home DS0000071031.V367347.R01.S.doc Version 5.2 Page 28 - 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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