Inspection on 21/09/05 for Samarie

This inspection was carried out on 21st September 2005.

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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Samarie 20/12/07

Samarie 17/08/06

Samarie 24/01/06

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 Jacqui Burvill Unannounced 21 September 2005 st 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 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 Stationary 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 D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Samarie Address Dunkirk Hill Devizes Wiltshire SN10 2BD 01380 739064 Telephone number Fax number Email 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 Mrs Tracey Brett Care Home 3 Category(ies) of LD Learning Disability (3) registration, with number of places Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th March 2005 Brief Description of the Service: Smarie is a private residential home. This is one of two homes owned by Mr and Mrs Jurkiewicz. Samarie provides care and accomodation for three service users who have a learning disability. The home is situated on the outskirts of Devizes, in a secluded 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 handwash basin. There is an additional bathroom. There is a large lounge, dining room and kitchen, with a utility area leading off of 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 accomodation is light and spacious. There is a 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. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours on 21st September 2005. One service user was at home and the other service users were at their day care services. The inspector spoke to one service user and the manager who was on duty. During the inspection, one of the owners visited and stayed. Menu records, medication and medication records, care plans, risk assessments, daily notes and activity notes, fire safety records and the accident book were seen. There was a partial tour of the premises, where the service user showed the inspector areas of the home. The service user said he was ‘quite contented’ living at Samarie. The service user talked about the activities and places he liked to go to, as well as friends he liked to meet up with. What the service does well: What has improved since the last inspection? What they could do better: The manager and responsible individual need to ensure that the correct forms are used when recording safety practices in the home. Incidents that involve service users had not been reported to the CSCI. Daily notes and the activity record needs to be combined, so that service users’ individuality and confidentiality is respected. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 6 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 D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed, as there have been no new service users admitted to the home. EVIDENCE: Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 Service users are not fully involved in their care plans and therefore may not have created their own goals. Service users make choices about things they like to do and staff support access to events or the community. Risks that affect service users have been assessed and reviewed to ensure their safety. EVIDENCE: One service user’s records were seen. The original care plan is in place, with any updates written and included in the file, so it is possible to review the changes that may have taken place. It is not clear if service users are aware of the content of their care plan or have any involvement in creating goals. There are two kinds of daily notes. One is a record with brief details from June to September and the other is in a bound book, which includes details of the all the activities that service users have taken part in. This record was not in place at the last inspection and the reason behind this change was discussed with the manager and the owner. These records are not confidential to the individual service user. Risk assessments are up to date and in place and relevant to the needs of service users. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 10 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 standard(s) 17 Service users have choices over their meals and enjoy a healthy and varied diet. EVIDENCE: Meals are recorded and show that service users are consulted about choices and preferences. On the day of inspection, the service user chose what they wanted for lunch and staff prepared this. Service users have access to the kitchen to make drinks and snacks if they wish to. Meals are taken in the dining area close to the kitchen, which is brightly decorated and homely in style. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 11 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 standard(s) 20 Aspects of poor medication record keeping may put service users at risk. EVIDENCE: Staff record health and medication needs on a document in the care plan file. This record shows what involvement there has been with other healthcare professionals and what action has been taken and needs to be followed up. Service users do not self -administer their medication. Staff support service users and use a medication dosette system to do this. Medication records show that staff have not used a separate box on the medication administration sheet when medication is altered. Previous medication records sheets showed that on occasions, staff did not sign the box to say that medication had been given. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 12 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 standard(s) 23 Service users are not fully protected by staff knowledge in adult protection and awareness of abuse. EVIDENCE: Staff have not received adult protection training and training in awareness of abuse. This was a requirement from the last inspection. The manager plans to use a training video and may devise a questionnaire for staff to complete. Staff have signed to say that they have read the policy and procedure. This includes the ‘No Secrets’ booklet. Only one staff member has dated their signature. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 13 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 standard(s) 24 The home is a safe and comfortable place for service users to live in. EVIDENCE: Samarie is a domestic style home, which is comfortable and has a homely atmosphere. There are budgies in the lounge, which the service users enjoy helping to take care of. The service user pointed out an armchair to the inspector that is in need of repair or replacement. The home does not have radiator covers. Each radiator has a warning sign and risk assessments are in place. The garden wall on the drive into the parking bay is leaning at an angle and will need to be rectified. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standard not assessed on this occasion. EVIDENCE: Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Fire safety checks are taking place, but poor record keeping could compromise service users’ safety. Incidents that affect or involve service users have not been reported to the CSCI. This affects the promotion of their health, safety and welfare. EVIDENCE: Fire records showed that the person completing had not used the correct form for a number of months. This had been noticed by the owner, who had decided not to correct this as he was satisfied that the smoke alarms and break glass points had been checked. Record sheets were slightly confusing as there are two years worth of records on one sheet. This means there is no space to record a full years worth of checks, possibly resulting in them not being completed for the last quarter. The means of escape form was being used to record checks on alarms. Fire drill records did not have details of the staff who had attended. Staff have Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 16 received fire safety training in July and September 2005, but the actual dates of fire safety training has not been recorded. The accident book was seen and showed that an incident took place that had not been reported to the CSCI by using a Regulation 37 notification. This was discussed with the owner and manager and a proforma was sent to the home after the inspection for them to use. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Samarie Score x 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 18 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 13(2) Regulation YA20 Requirement The medication administration sheet must be completed by the staff member who has administered it, every time a service user has medication. (Carried forward from the last inspection. Due to be completed by 31st March 2005) Staff must receive medication training and their competency to manage medication and acompanying medication administration records must be assessed. When medication is altered, a separate box on the medication administration sheet must be used to record this. The proprietors must ensure that arrangements are made, by training or other means in prevention and risk of harm to service users.( Carried forward from last inspection. Due to be completed by 30th May 2005) The manager plans to hold in house training for the staff team, who have signed to say they have read the homes policies and procedures in adult Timescale for action 10th October 2005 and from now on 2. 13(2) YA20 30th December 2005 3. 13(2) YA20 4. 13(6) YA23 10th October 2005 and from now on 30th December 2005 Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 19 protection. 5. YA24 23 (2) (b) The garden wall surrounding the lawn and on the edge of the drive must be repaired so that it is upright. When accidents or incidents or any other event detailed in Regulation 37 occurs in the home they must be reported to the CSCI using Regulation 37 notifications. 30th March 2006 10th October 2005 and from now on. 6. YA42 37 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA6 YA6 YA24 YA42 YA42 YA42 YA42 Good Practice Recommendations Care plans should be in a format that is suitable for service users to read and understand. Care plans should be written in consultation with service users and reflect goals and interests they may have. The armchair with the sagging seat in the service users lounge should be replaced. Fire safety record sheets should be used for one complete year at a time. The correct fire safety record sheet should be used to record the tests and checks that are taking place. The responsible individual should obtain the Wiltshire Fire Brigades distance learning pack, for fire safety training in home. The actual date fire safety training took place should be recorded above the staff signature. Samarie D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 D51_D01_S28203_SAMARIE_V246253_210905_Stage4.doc Version 1.40 Page 21 - 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. 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