CARE HOME ADULTS 18-65
Samarie Dunkirk Hill Devizes Wiltshire SN10 2BD Lead Inspector
Jacqui Burvill Key Unannounced Inspection 17th August 2006 09:30 Samarie DS0000028203.V307754.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 Samarie DS0000028203.V307754.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. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Samarie Address Dunkirk Hill Devizes Wiltshire SN10 2BD 01380 739064 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 Sally Ann Jurkiewicz Tracey Dawn Brett Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Samarie is a private residential home. This is one of two homes owned by Mr and Mrs Jurkiewicz. Samarie provides care and accommodation for three service users who have a learning disability. The home is situated on the outskirts of Devizes, in a semi rural setting with panoramic views over the surrounding countryside. Samarie is an extended bungalow. Each service user has their own bedroom; one of these has an ensuite shower, toilet and hand washbasin. There is an additional bathroom. There is a large lounge, dining room and kitchen, with a utility area leading off the kitchen. At the far end of the bungalow, there is a conservatory, which can be used by service users. Access to the room is through the staff sleeping in room and office, although there is a door leading to the garden. The accommodation is light and spacious. There is a large garden to the front and side of the home, with seating. There is always at least one member of staff on duty and one member of staff sleeps in at night. Fees range from £750 to £826 per week. Inspection reports are available in the home. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection took place on two visits to the home, on the 17th and 22nd August 2006. On both occasions, the manager was met with. All three service users were met with over the two visits. Surveys were sent to the service users and their relatives, and a full response was received. There was a full tour of the premises and the following areas were looked at; care plans and daily notes, risk assessments, staff training and recruitment, medication, menus, complaints and adult protection, fire and health and safety, quality assurance and some policies and procedures. There was an immediate requirement set at the first site visit as two newly recruited staff members each had one reference in place. This was addressed by the registered manager immediately and by the time of the second site visit, additional references had been received for both staff members that were satisfactory. What the service does well:
There were positive comments on two of the relative surveys returned. One relative said a concern they had over passive smoking in the home had been satisfactorily addressed. Another survey comment described how their relative is always happy and loves living at Samarie. They went on to say; ‘the care in my opinion is excellent and I have no complaints whatsoever.’ Care plans are detailed and describe accurately how service users are to be supported. Service users have been involved in all aspects of the care plan and understand what they contain. Any special restrictions or arrangements are clear for staff to follow and service users have agreed with this. Keyworkers complete a ‘periodic monthly review’ for each service user. This looks at all the past month’s events and sets out any action or changes that may need to take place. Service users are supported to maintain links with friends and family, which is important to them. Service users also have interesting and active lives, attending day care, and events and activities in the community.
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 6 Medication records are in order and most of the staff team have a certificate in safe handling of medication. Service users are supported by the staff team in this, as none of them self medicate. Service users enjoy a healthy and varied diet, and this is supported by a clear approach to menus and care plans where appropriate in the home. They are able to make their own drinks and snacks as they want to. Service users have a comfortable and spacious home, with a large garden, which they enjoy using especially in good weather. What has improved since the last inspection? What they could do better:
The manager should ensure that there is a record in place for the disposal or return of any medication in the home. Although there is a monitored dosage system, there may be occasions when medication is stopped or altered and medication may have to be returned to the pharmacy. This would help to promote safe practice in handling medication. The remaining staff team need to undertake the safe handling of medication training, to ensure that all staff are competent to do so. Where there is a perceived risk that is having an impact on the life of the service user, and which they may not agree with. Advice and liaison should be
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 7 sought from other health and social care professionals to review and re-assess the risk, so the service user retains as a high a quality of life as possible. There are some improvements required as the patio has some cracked and loose slabs just outside the dining room and under a bedroom window towards the end of the home. One of the bathrooms is in need of replacement or repairs to the tiling, as some tiles are loose and cracked. The manager must ensure that the recruitment practice is always robust and that it protects service users. During the inspection process, an immediate requirement was issued so that the manager obtained one more reference each for two new staff who had been employed. There was no evidence that these staff had received an induction. At the second visit to the home, a form had been set up in order that these staff could have their induction recorded. This helps to ensure that the manager has competent and adequately trained staff on duty at all times. A quality assurance report needs to be written, following further questionnaires being sent to service users. This is a continuing requirement, as a report concluding the previous questionnaires was not received by the specified date. This report should show the continuing development and improvements in the home, which will be planned and actioned as a result of the survey. 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. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This standard was not assessed on this occasion as the service users have lived at the home for a number of years and the home is full. EVIDENCE: Samarie DS0000028203.V307754.R01.S.doc Version 5.2 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): 6, 7, 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users know and are aware of the details in their care plan, are supported to make decisons and have been consulted about this. Risks are assessed and in the main, support service users to live an independent lifestyle. More consultation about one service users’ lifestyle needs to be considered to ensure this. EVIDENCE: Each of the service users’ care plans were looked at. Each file is divided up into sections relating to the needs of the service user. This includes sections on physical health, house programme, personal hygiene, personal finance, family, medication and social skills and social network. The sections also describe whether there has been a change to the care plan and these are dated and signed. The whole care plan is signed and dated by the service user and the manager.
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 11 There is a description of the keyworker role in conjunction with the service user’s agreement, which describes how they are expected to support the service user through conversation, attending meetings and appointments and arranging family contact. Service users help to set objectives, which are to be reviewed in October 2006. This includes specific activities that service users have taken part in. However it was noted that the record of these activities only covered the period of 12/11/05 – 24/04/06. Where appropriate there are risk assessments in place. In one case, these were discussed as they had been advocated by a health care professional. Despite the fact the service user’s health had improved, the risks had not been re-assessed. The inspector and manager discussed this and the inspector advised that a multi agency meeting should take place to assess the risks in light of a recent assessment. The service user has expressed their concern about how this has restricted their lifestyle in a way they feel is unnecessary. Risk assessments should be proportionate to the risk that is likely to occur and not restrict the choices and lifestyle of service users. There is another restriction that applies with regard to one service user, in the way they are supported with managing their personal finances. This has been agreed jointly with the care manager. Staff have clear guidance by following signposts to records in the home about how the service user is supported. This approach has made a tremendous reduction to the distress the service user had experienced in this area in the past. Keyworkers complete a ‘monthly periodic review form’ for each service user. This record looks back over all the records kept in the previous month and describes the actions that have taken place, or significant events. It is a clear and objective record and shows that all aspects of each service user’s life is reviewed and documented. Service users commented through the surveys that they were able to make choices in the home. Service users spoke about what they liked to do both inside and outside of the home. This included going to day care, being supported to look for jobs, going shopping, or meeting friends and family. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 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): 12, 13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from and enjoy taking part in a variety of activities and some are exploring new opportunities for the future. Service users appreciate and like meeting their friends and family both within the home and in the local community. Service users’ rights and responsibilities are reflected in their daily lives. Service users benefit from a varied and healthy diet, which they are able to take part in and make choices about. EVIDENCE: Each service user has a description of their activities and two of the service users have a wide range of activities in the local community. There have been recent changes to this. By the day care centre, which has affected the service users.
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 13 One service user is being supported by the employment opportunity group and has been attending interviews for jobs. Service users live close to Devizes town centre and enjoy visiting the town and other nearby places of interest. Family and friends are welcome at the home at any time, and service users are also supported to visit and spend time with their families. One service user showed the inspector their own diary, with the dates of planned visits to family members. Service users are aware of the content of their care plans and risk assessments and as such are as involved as much as possible in understanding their rights and responsibilities. They have a lockable space and a key to the home and take part in household tasks. Service users were observed making their own drinks and snacks in the kitchen and asking other service users, staff and visitors if they would like a drink too. There are two budgies in the home and one of the service users helps to care for them. Service users choose meals by describing their ideas. The record shows details of choices made and includes details of packed lunches. One service user has a high protein diet because of a health need and this is well described in the care plan. There is a policy and procedure about meals and mealtimes, which sets out in principle the approach and values. Meals are unhurried and can be taken at varying times, to fit in with the service users’ lifestyle and choices made dependent on the weather. For example, there were more salads and barbeques in the warmer weather, which were eaten outside in the garden. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 14 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive personal care in the way they prefer and their physical and emotional health needs are met. Service users are supported by staff with regard to medication. One element of medication recording and more staff trained in safe adminsitration of medication would improve service users’ protection. EVIDENCE: Each service user has a section in their file which relates to their healthcare needs. This describes appointments and actions to be taken as a result. There is clear evidence that service users are well supported by the staff team who are aware of their needs and that there is liaison with community health and social care services. Service users are supported in managing some aspects of their personal care, but in general, are able to do this with minimal support. As a result, there have been no issues or concerns from the service users about staff of a different
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 15 gender providing personal care support when bathing or dressing, as support is more of a prompt than actual assistance. The medical treatment log sheets show accurately when staff have supported service users in managing their health care needs at home. There is also a record that shows what medication is administered by health care staff at a nearby hospital. Medication records were in order. The home uses a monitored dosage system. The local pharmacy supplies medication to the home. There is no record of medication disposed or returned and this is because no medication has needed to be returned or disposed of. The manager was advised to ensure that a record was place should this ever be needed in the future. One service user is being supported through a reduction and change in medication, which is being overseen by a senior healthcare professional. Three out of the six staff have not received medication training yet and do not administer medication. There is a medication policy and procedure. None of the service users self medicate. There is guidance about homely remedies. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 16 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives feel their views are listened to and acted on. The majority of staff are trained in understanding the vulnerable adult procedure and signs and symptoms of abuse and they have access to policies and procedures describing what to do. This ensures service users are protected from abuse. EVIDENCE: There have been no complaints since the last inspection received either by the home, or the CSCI. Two of the three relatives commented on the survey that they were aware of the complaints procedure and that one had made a complaint/ comment, which had been satisfactorily addressed. This was about the issue of passive smoking in the home. Arrangements were discussed and agreed and put in place, so that the home is a non smoking environment. Service users who wish to smoke now have designated areas, which do not impact on the lives or health of other service users. Service users commented through the survey that they knew who to speak to if they had a complaint and named staff who they felt would support them. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 17 There are abuse polices and procedures in place. There are descriptions in the policy about different types of abuse and staff sign to say they have read it. Staff are also provided with their own copy of the ‘No Secrets’ booklet. There are additional policies on bullying and harassment, whistle blowing and aggression towards staff. The policy contains a copy of the flow chart showing how an ‘alerter’ can make a referral to the Vulnerable Adult Unit. As previously mentioned, there is a restriction in respect of one service user in how they are supported to manage their finances. There is suitable documentation in the home to support this. Records for one service user were checked and these were in order. There have been no referrals to the Swindon and Wiltshire Vulnerable Adult Procedure. There was a requirement at the last inspection that staff receive training in adult protection. Four of the staff employed at the time have now received this training, two staff who have been recently employed still need to attend. This training was provided by an external provider. Further information about this can be found in the staffing section of this report. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 18 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users enjoy living at the home, which is comfortable, homely, clean and hygienic. Replacement or repair of some patio slabs and a small number of bathroom tiles will enhance the accomodation. EVIDENCE: Samarie is a detached bungalow set in its own grounds, with panoramic views over the surrounding countryside. The home is not far from Devizes town centre. Each service user has their own bedroom. Bedrooms are reflective of the service users’ own interests. There are two bathrooms. There is a large sitting room and a separate dining room and kitchen. Just off the kitchen is a utility room, which also doubles as a smoking area in bad weather. There is an additional sitting room in a conservatory at the far end of the home, next to the staff office and sleeping in room. The home is spacious, light and airy. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 19 There have been some improvements to the home since the last inspection. This includes new fencing that has been erected along the boundary of the property next to a public footpath. The lounge is in the process of being redecorated and service users have been involved in choosing the colour. There are plans to replace the seating in the lounge. One of the seats is very low and difficult to sit in and get out of. The patio just off the kitchen needs to be repaired or replaced as some of the slabs are cracked and uneven. One of the bathrooms needs some broken tiles replacing. The home was clean, tidy and smelled fresh at the time of the site visit. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by a staff team who have knowledge of their needs, but this would be further enhanced by staff who have National Vocational Qualifications. The home’s recruitment practice must ensure that it always protects and supports service users, by obtaining two references prior to employment starting and by new starters completing an induction programme. EVIDENCE: Staff training and recruitment records were looked at. There was a previous requirement that staff training records must be in place. This requirement has now been met. At least one member of staff is on duty at all times. The owner of the home also visits the home and supports the service users daily. Staff have received training in basic food hygiene, first aid, disability equality, equality and diversity, adult protection, infection control, and the safe handling of medication. Much of this training has been sourced through external providers.
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 21 One staff member has completed National Vocational Qualification at level 2 and has registered to start NVQ level 3. Another staff member has NVQ level 2. This means that there are 33 of the staff team with an NVQ, which is below the expected standard of 50 . Funding has been applied for two staff to commence NVQ training at level 2. The home has not been informed about the Learning Disability Award Framework, which ensures that staff who do not have a background in learning difficulty services can develop underpinning knowledge, which counts towards NVQ level 2. Two new staff have been recruited since the last inspection. Criminal Record Bureau checks had been carried out prior to their appointment, but only one reference had been obtained in both cases. There had been a delay in obtaining these of over eight weeks and in the meantime, they had started work. Two references had been requested, but had not been received. As a result, an immediate requirement was set on 17th August and at the next site visit on 22nd August, the two new references were seen and were satisfactory. New staff come for a 2 – 3 week period, so as to meet service users and be introduced to them. Newly appointed staff then shadow experienced staff as part of the induction period. During this time, new staff are required to read the policies and procedures and sign to say they have done so. Evidence relating to the induction of new staff could not be found. This was discussed with the manager. At the time of the second site visit, an induction programme had been devised, which would equip staff with the information they need in order to carry out their roles safely and effectively. Part of this is staff knowledge and understanding of adult protection. There was no evidence that the two most recent employees had received this training as part of their induction. It is a requirement from this inspection that staff complete an induction programme within three months of their employment. It is a recommendation that new staff register with the Learning Disability Award Framework to provide underpinning knowledge. Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 22 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 was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a well run home. Service users do not yet benefit from a comprehensive quality assurance system, that underpins self-monitoring and development in the home. The health, safety and well being of service users is promoted. EVIDENCE: The registered manager is awaiting her certificate for NVQ level 4 and the Registered Mangers Award. This has been delayed due to issues with the company who provided the assessors, which ceased to operate. The manager has been in post for 2 years and has devised systems, which support the record keeping and promote the safety and well being of service
Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 23 users in the home. The manager is interested in further developing her Information Technology skills. The service users’ quality assurance questionnaires were completed in August 2005. Questionnaires from outside agencies and family and friends have been completed in March and April 2006. Due to the lapse of time between the groups of surveys, the inspector advised that the service users’ surveys are done again and then the report can be collated looking at the finding of the survey. Any improvements should be linked to an action plan. The manager has already devised an action plan for improving the environment. This is a continuing requirement as this was due to be completed by 30th March 2006. Fire safety records were looked at. Safety checks are taking place at appropriate intervals. Staff have received fire safety training and it is a recommendation that staff record the actual date they received the training above their initials. The fire risk assessment is up to date and includes individual rooms in the home. Other safety checks are in place, with risk assessments in place for radiators. There are plans to cover these in the near future. Samarie DS0000028203.V307754.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 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 X 2 N/A 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 3 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 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) 18 (1) (a) (c) (i) (ii) 23 (2) (b) 23 (2) (b) Requirement The three staff who have not received medication administration training must do so. The bathroom near to the dining room must have the tiles replaced or repaired. The patio area outside the dining room and towards the end of the property close to the entrance must be repaired or replaced. Recruitment checks must be robust and include obtaining two references including one from the last employer prior to employment starting. Newly recruited staff must complete an induction within three months of employment. A copy of the quality survey report must be sent to the local CSCI office. COMMENT: The surveys are not complete and results have not been collated. This was due to be completed by 30/03/06 Timescale for action 31/12/06 2. 3. YA23 YA23 31/10/06 31/10/06 4. YA34 19 (1) (c) Schedule 2.3 18 (1) (a) (c) (i) (ii) 24 (2) 30/09/06 5. 6. YA35 YA39 31/10/06 31/12/06 Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations Where a service user’s lifestyle has been restricted due to perceived risk, this should be re – assessed in liaison with the relevant social and healthcare professionals. A record for disposal or return of medication should be set up in anticipation of it ever being needed. One of the armchairs in the lounge should be replaced as it is too low for service users to use. When staff complete fire safety training, they should record the actual date training took place above their initials. 2. 3. 4. YA20 YA23 YA42 Samarie DS0000028203.V307754.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Samarie DS0000028203.V307754.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
