Inspection on 20/12/07 for Samarie

This inspection was carried out on 20th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Samarie 17/08/06

Samarie 24/01/06

Samarie 21/09/05

Samarie 16/03/05

Samarie 05/10/04

Samarie 02/02/04

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 Samarie Dunkirk Hill Devizes Wiltshire SN10 2BD Lead Inspector Nichola Grayburn Unannounced Inspection 20th December 2007 09:30 DS0000028203.V340409.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 DS0000028203.V340409.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. DS0000028203.V340409.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) Mr Henryk Andre George Jurkiewicz Tracey Dawn Brett Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000028203.V340409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 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 is registered to provide 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. DS0000028203.V340409.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Samarie’s key inspection. The inspector rang the day before to check that there was someone available for the inspection. Prior to the inspection, previous records and reports held at the Commission for Social Care Inspection were read. The new legal self-assessment from the Commission for Social Care Inspection called the Annual Quality Assurance Assessment (AQAA) was completed and returned. This gives information regarding the service including details relating to each of the headings below. Surveys were sent for people living at the home; the manager; staff; relatives; health care professionals to fill out. 2 ‘service user’ surveys; 5 relatives’ surveys; 2 manager’s surveys; 4 staff surveys; and 1 health care professional survey were returned. The results of the surveys form part of this report. The inspector met people who live at the home, staff; the Manager and provider on a one-to-one basis; and undertook a tour of the property, and read key documents. 2 residents were case tracked. Verbal feedback was given at the end of the inspection to the Manager. What the service does well: Samarie is a small homely home. People have lived there for a number of years and are happy to be living there. People have lifestyles which suit their routines and choices. People’s health needs are met and staff contact relevant professionals when necessary. Where appropriate, people maintain good contact relationships with their family members. Relatives added comments on their surveys: “I think they very much do a wonderful job, is home form home, and all the staff are great and always make you most welcome.” “This is the best care home *** has ever been in, the staff are wonderful” DS0000028203.V340409.R01.S.doc Version 5.2 Page 6 “Samarie is an excellent care home with terrific staff” “On occasions when we have met *** out and about, he is always happy and well groomed. When I visit the home, staff are always friendly and welcoming. Staff make time for you, and keep me well informed of any changes.” 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. The summary of this inspection report can be made available in other formats on request. DS0000028203.V340409.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 DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is adequate. The home’s Statement of Purpose needs updating to ensure that prospective people can make an informed decision about whether to live there or not. People’s needs are assessed and reviewed prior to moving into the home. People’s needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Samarie’s Statement of Purpose and Service User Guide was read during the inspection. It was discussed with the manager that it needs more detail regarding the admissions procedure and the opportunity to make visits to the home. It also needs updating regarding the complaints procedure and the size of rooms needs to be included. The documents are not particularly user friendly and it was also discussed with the manager how they can be in an easier format for people to read and understand. The updated version must be sent to the Commission for Social Care Inspection once completed. There is currently a vacancy at Samarie. The local social services authority is aware of this and the manager is writing to them with more information about the home. The updated Statement of Purpose will help prospective people to make an informed decision about whether to move in or not. DS0000028203.V340409.R01.S.doc Version 5.2 Page 9 No one has moved into the home for a number of years and the manager must ensure that people have the opportunity to ‘test-drive’ living at the home prior to making a decision. People’s care files have current reviews by the person’s social worker. As evidenced throughout this report, people’s needs are met at Samarie. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is good. People living at the home have individual care plans to ensure that their needs are met. People are supported to take risks as part of their everyday life. People are able to make decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home have care plans in place within their files detailing what support they need from staff. Each person has a key worker who ensures that appointments and needs are met. People have regular reviews with their social worker from their funding authority. These are kept on their file. Surveys from people living at the home stated that they can make decisions about what they each day, and can do what they want during the day, evening and on weekends. Someone added ‘I’m always given choices’. DS0000028203.V340409.R01.S.doc Version 5.2 Page 11 Risk assessments are in place and are reviewed on a regular basis. Restrictions regarding certain activities and behaviours are recorded and the risks are minimised with support from staff. Within staff files, a confidentiality clause has been signed by the staff member to ensure that people’s confidences are not breached. Records are kept safe and secure within the home. As written under ‘Personal and Healthcare Support’, people’s confidences regarding their health was respected and family were only informed when the person wanted them to know. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. People have lifestyles, which suits their choices and routines. People are supported to maintain their relationships with family and friends. People are offered and provided with a varied and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People living at the home have lived there for a number of years and have established lifestyles and routines. The home have explored employment links with people living at the home within the local community and the local job centres. The AQAA stated that they have maintained these links and the outcomes were discussed during the inspection. Unfortunately, due to various reasons, people have not been able to secure jobs. DS0000028203.V340409.R01.S.doc Version 5.2 Page 13 People told the inspector about their daily activities, such as going to local day centres, going into town, attending appointments. It was also evident from records and discussions that people have contact with their family. Some people have more contact than others. People have the option of going on annual holidays away from the home. People living at the home told the inspector about these and how much they enjoyed them. Someone added in their survey that ‘they are always arranging trips, activitities.’ It was observed how people have access to all areas of the home and can choose whether to spend time on their own or with each other or with staff. The manager confirmed that she had asked people whether the inspector could look at their rooms prior to the inspection. People told the inspector that they clean their own bedroom and also share the communal chores such as hovering and laying the table for dinner. Relatives added “*** is allowed to use the telephone when he would like”. “They treat *** as an individual...is treated with respect.” The home is smoke-free, but people can smoke in the utility room and the conservatory. A record is maintained of what people eat at home. The records were read for the past few weeks and showed that a varied and nutritious diet is provided such as chicken salad; homemade soup, and cheese omelette. The kitchen was clean and had a good stock of foods. The manager does the shopping and sometimes people living at the home go with her. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. People’s personal and healthcare needs are met with the support from staff. People are protected by the home’s medication procedures. People’s wishes regarding their illness and death are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives added in their surveys that “***’s health needs are always met”; and “***’s concerns taken into account plus his choices.” The survey from the health care professional stated in their survey that the home ‘always’ meets the care needs of people. Records showed that people are supported to attend the health appointments (opticians, dentist) they decide they want to go to. People living at the home said that they don’t go to certain appointments, which is their choice. Those people who have epileptic fits, have ‘seizure charts’ in place to record the frequency to inform the relevant health care professional and so that the DS0000028203.V340409.R01.S.doc Version 5.2 Page 15 home can monitor their health. Referrals have been made to the relevant professionals to review and update issues regarding people’s epilepsy. The home’s medication system was inspected. People living at the home have medication profiles within their care files, and also have regular medication reviews to ensure that their medication is correct according to their needs. Due to recent medication needs, the home installed a safe to keep controlled medication. The manager was aware that they had to keep the medication for 3 days after a death before returning it. No one in the home looks after their own medication. All the Medication Administration Records had been signed correctly. A requirement had been made at the last inspection for all staff to receive medication training, which has been complied with. Staff now do a 10-week course at the local college. The home has recently experienced a recent death of a person living in the home. The wishes of the individual had been recorded previously and were dutifully followed regarding funeral arrangement. The persons wishes regarding their illness and informing people were also dutifully followed. Family members were involved throughout and had sent a thank-you card to the home for all their efforts. This incident and events leading up to it have affected the home greatly. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. People are able to make complaints and feel that they are listened to and staff would act on their concerns. People are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints received by the Commission for Social Care Inspection since the last inspection. The AQAA stated that the home has not received any complaints either. The home has their complaints policy on display in the kitchen, which details the procedure which people can follow. The Commission for Social Care Inspection’s contact details need updating. People living at the home completed their surveys stating that they know how to make a complaint and who to speak to if they are unhappy, and gave examples of whom they would speak to. The health care professional survey also confirmed that the service has ‘always’ responded appropriately if they needed to raise any concerns. All 5 relative’s surveys stated that they know how to make a complaint and have responded appropriately. There were added comments of “staff are always willing to discuss any issues with you”. The AQAA confirmed that no referrals have been made to the local authority regarding protection issues. People living at the home stated on their surveys that the staff ‘always’ treat them well, with an added comment “all the staff treat me well.” There is a clear flow chart in the office explaining the process of reporting allegations of abuse, with phone numbers. Staff are given DS0000028203.V340409.R01.S.doc Version 5.2 Page 17 information within their induction regarding the protection of vulnerable adults (‘No Secrets’) and sign to confirm that they have read and understand the issues and procedures associated with it. Staff have undertaken training in the ‘Protection and Well-being of Individuals’ within their National Vocational Qualification. The manager is trying to secure funding for specific training in the Protection of Vulnerable Adults as there have been problems with accessing it. It is recommended that this is attained and for staff to attend annual refresher courses. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 Quality in this outcome area is good. People live in a comfortable and clean environment. People have personalised bedrooms which also promote their independence. There are large shared spaces which people can use as they wish. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Samarie is an extended bungalow situated on the outskirts of Devizes, in a semi rural setting with panoramic views over the surrounding countryside. It is quiet and peaceful. The home is light and spacious. There is access for people who use a wheelchair. Each service user has their own bedroom; one of these has an ensuite shower, toilet and hand washbasin. All 3 bedrooms were looked at and were personalised with pictures and personal effects. One bedroom has en-suite facilities. It was noted that there are parts of the room, which have signs of damp which need attention. There is an additional DS0000028203.V340409.R01.S.doc Version 5.2 Page 19 bathroom off the hallway which has a bath with a shower. A requirement was made at the last inspection for one of the tiles to be repaired along the bath side. The manager confirmed that this had been done but more have since fallen off, but due to recent unforeseen circumstances, it has not been a priority. It is not safe or hygienic. The requirement remains with a new timescale. There is a large lounge, which overlooks the countryside and people living the home commented on how they like looking out over the fields. Re-painting of the lounge has started and will continue and finish in the very near future. The radiators have protective covers round them. One in the lounge needs attaching which was highlighted to the provider who said that it would be fixed. The home was nicely decorated with Christmas decorations. There is an open plan kitchen with a large dining room, which is homely in appearance. There is a utility area leading off from the kitchen where people can use the washing machine. The space is also used for storage. 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. There is a large garden to the front and side of the home, with seating. A requirement had been made for the patio to be repaired or replaced and this has been complied with. A relative added on their survey “a lovely clean and hygienic place to stay/visit” The home was clean and hygienic on the day of the visit. People living at the home said that they clean their own room, and enjoy doing so, and also stated on their surveys that the home is ‘always’ fresh and clean. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good People living at the home are supported by a qualified staff team, who are supported by their manager. Staff are not fully trained in mandatory areas to ensure that people are fully supported. People are protected by the home’s recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A relative added on their survey that “staff go the extra mile to ensure *** is well looked after and cared for” A small team supports people at Samarie. There are 3 full time and 3 part time staff. A requirement was made at the last visit to ensure that staff complete an induction programme within 3 months of their employment. Evidence was seen regarding this and the manager explained the process. Staff’s induction is carried out over a period of days. As the home is small, the manager is able to spend time with new staff to ensure that they are fully aware of the needs of people living there. DS0000028203.V340409.R01.S.doc Version 5.2 Page 21 Some staff records were checked and contained the relevant recruitment documents, such as a completed application form; 2 references and the person’s Enhanced Criminal Records Bureau check. Some people had character references instead of a previous employer as a second professional reference was unobtainable. This was discussed with the manager. The AQAA and records evidenced that nearly all the staff have completed their National Vocational Qualification in care. Staff have copies of their job descriptions within their files which explains what they have to do whilst at work. Some training records were looked at. Staff have undertaken training in some mandatory areas such as Emergency First Aid; food hygiene; equalities and diversity, and administering medication. However, training is not consistent within the team, and staff need to do training in areas such as manual handling and infection control. Some staff did mandatory training but in 1999 and need refresher courses due to the changes in legislation and practice. The manager has identified staff’s training needs and explained the problems with accessing training providers within their budget. A requirement has been made regarding this to ensure that people living at the home are supported by a trained staff team. Due to the problems, a realistic timescale has been given. Staff meetings are relatively regularly. The last two sets of minutes were read. It stated that people living at the home declined to join them. The manager carries supervision meetings with the staff team. Records of these were read and evidenced that there are regular. A form is given to staff prior to the meeting for them to complete to give them the opportunity to write down any concerns they have about their work. It was observed and the manager explained that as the staff team is small, any concerns are raised immediately and dealt with. DS0000028203.V340409.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 Quality in this outcome area is good. People live in a well managed home with good systems in place. People are protected from health and safety risks. Good records are kept securely evidencing the support given to people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector met both the manager and the provider on the day of the visit. Ms Brett has been the registered manager at Samarie since 2005. Ms Brett has achieved her Registered Managers Award and had completed her NVQ level 4 but due to circumstances, which were out of her hands, she has to redo it. The AQAA was filled out and returned to the Commission. It was discussed how it could be completed with more detail regarding the service in light of future inspection methods. DS0000028203.V340409.R01.S.doc Version 5.2 Page 23 It was evident from speaking with staff and people living at the home, the management ethos in the home is open and transparent. People living at the home spoke positively and warmly about the management. The provider visits the home often. It was observed and the manager explained that any concerns she has, the provider is available and offers guidance and support when necessary. The home has a designated quality assurance folder. Questionnaires were carried out with people living at the home in September and October 2006. The results were positive. It was discussed with the manager how improvements within the home could be made from the answers and recorded what has been done to improve, or why it can’t be improved. The manager confirmed that they will be doing another questionnaire early 2008. It was also discussed that information can be gathered from other people who visit the home in order to gain a wider insight. The compiled results from the next questionnaire must be sent to the Commission for Social Care Inspection. Staff keep up-to-date records regarding the care and support given to people living at the home. These are kept secure in the office. Notes written appropriately, positively, and with a person centred approach. Records are organised and staff can find information easily. Records were seen and showed that staff carry out regular fire safety checks. An external fire security contractor visited the property in June 2007 and found the home to be satisfactory. People in the home and staff carry out fire drills regularly and records show that people leave the building straight away. It was discussed with the manager that she must ensure that night staff are involved in the fire drills every 3 months. There is a fire safety risk assessment in place and is reviewed annually. It was discussed with the manager, if people’s needs change, i.e. mobility needs, the assessment has to be reviewed accordingly. The Portable Appliance Testing had been carried out in December 2007 but some of the electrical equipment needs testing to ensure that they are safe to use. The manager confirmed that she would contact their contractor to complete the testing. Other health and safety checks, such as gas and electrics are checked regularly. DS0000028203.V340409.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 2 2 3 3 3 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 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 X 3 X DS0000028203.V340409.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation Schedule 1 4(1c) Requirement The home’s Statement of Purpose and service user guide needs updating and in a format which people can use. This must be sent to The Commission for Social Care Inspection. Staff to undertake mandatory training to ensure that people are supported by a trained staff team. The bathroom near to the dining room must have the tiles replaced or repaired. (Outstanding requirement, previous timescale, 31/10/06, see text for further information) Timescale for action 28/02/08 2. YA35 18(1a, c) 30/06/08 3. YA23 23 (2) (b) 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000028203.V340409.R01.S.doc Version 5.2 Page 26 No. 1. Refer to Standard YA23 Good Practice Recommendations Staff to undertake PoVA training. DS0000028203.V340409.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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