Inspection on 18/04/07 for Sampson Court

This inspection was carried out on 18th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sampson Court 17/08/06

Sampson Court 01/03/06

Sampson Court 09/09/05

Sampson Court 17/03/05

Sampson Court 07/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Sampson Court Mongeham Road Deal Kent CT14 9PX Lead Inspector Joseph Harris Key Unannounced Inspection 18th April 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sampson Court Address Mongeham Road Deal Kent CT14 9PX 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) 01304 360909 Kent County Council Post Vacant Care Home 35 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (18) of places Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents to be aged fifty five (55) and over Date of last inspection 17th August 2006 Brief Description of the Service: Sampson Court is a 35 bedded home for Older People run by Kent County Council in the town of Deal. The service provides accommodation for people requiring dementia care and a residential service for older people over the age of 65. The home also provides a respite service. The home is situated in a residential area on the outskirts of Deal around two miles from the centre of town. There is a bus service that passes nearby into the town centre, which has good amenities and a range of facilities. The home is set over a single floor and has a dedicated EMI unit. All of the bedrooms are single occupancy and are reasonably well furnished. There is a good amount of communal space available in both sections of the home with open plan lounges and dining areas. There is a garden surrounding the building, which is accessible to the service users. The current fees for the service at the time of the visit range from £343.33 to £364.79 per week. Information on the Home’s services and the CSCI reports for prospective service users should be detailed in the Statement of Purpose and Service User Guide. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection process culminated in a site visit to the home on Wednesday 18th April 2007. The visit commenced at approximately 9.30am and concluded at 3.30pm; lasting around 6 hours. During the course of the site visit discussions were held with service users, visiting relatives, care staff, team leaders and ancillary staff. A tour of the premises was conducted. A range of documents and records were examined including service user plans, staff personnel records, health and safety documentation, medication records and other information relating to the running of the home. What the service does well: What has improved since the last inspection? Some improvements have been made within the care planning process and assessment of service user’s needs, although this is an area that continues to need to be developed. Improvements have been made to the general environment and ambience of the home including new carpets and lighting. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 6 There has been an improved focus on activities with development of activity planners and a concentration by care staff in this area. Observations confirmed that service users are engaged by staff throughout the day in both formal and informal activities. However there remains further scope for improvement in this area. Staff personnel files have been updated to include all required information. 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. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. Prospective service users are given adequate information about the home and have their needs assessed prior to moving in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has developed a service user’s guide and a statement of purpose enabling prospective service users and their relatives to make an informed choice about the home. However, it is recommended that the Service User’s Guide in particular is reviewed and updated by the newly appointed manager. During the site visit 3 different service user guides were examined each developed by previous managers. The most recent of which contains a reasonable amount of jargon and was not easy to read. It is also presented in Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 9 an A5 booklet in relatively small print, which may prove a difficulty for people with visual impairments. Refer to recommendation 1. It is also advised that the service user guide concentrates on the details that prospective service users need to know such as mealtimes, activities, facilities, accommodation, etc including all additional required information towards the back of the guide. It is also suggested that the home develops a spoken word version of the guide for service users who have significant visual impairments. Copies of the guide should be made available throughout the home and provided to all prospective service users. The home has a clear and comprehensive contract in place covering all necessary information including fees, additional costs and rooms to be occupied. The contract is well written and in fairly large print. All service user files examined had an up to date contract on file, which had been signed by a home representative and the service user. It was noted that service users on the dementia care unit (Skylark) had signed their own contracts, which does raise the question of capacity to understand and accept the information contained. Therefore the home should ensure that contracts are signed and agreed by the service user and/or the nominated representative where issues of capacity to understand are present. Refer to recommendation 2. 4 service user files were examined during the course of the site visit, all of which had up to date pre-admission assessments on file. The assessments address all areas of need, support and care in suitable detail for the home to assess the appropriate nature of the referral. All service users are referred through care management and a copy of the assessment is received in all cases prior to the resident moving into the home. The plans of care developed in each case reflected the assessed needs. It was noted by some staff members that there is an element of pressure placed on the home by care managers at times to accept service users who the home feels they could not meet the needs of. It was reinforced by the inspector that it is the responsibility of the home to only accept service users who can have their needs fully met by the service. The home does provide dedicated respite/intermediate care beds on both the residential (Nightingale) and Skylark units. There are allocated bedrooms set aside for clients requiring short-term care and access to an integrated day service within the home. All clients referred for respite care are subject to preadmission assessments and have a plan of care developed on admission. The inspector spoke to a number of service users receiving respite care. One person said, “I was worried about coming at first, but I’ve enjoyed my time here. I’d definitely be happy to come back if I needed to”. Another person said, “I’ve been so well looked after, it’s been like a holiday”. The relative of one respite client said, “My mother has had wonderful care, it’s been a relief to know that she’s been so well looked after. All the staff have been fantastic.” Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. Service users know that their health and personal care needs will be met in respectful and dignified manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four individual service user plans were examined during the course of the inspection including those for 2 respite clients and 2 dementia care clients. In all cases a plan of care had been developed, which reflected the needs outlined in the assessment of needs. It was evident that some progress has been made in developing individual plans and in one case the needs and actions required by staff to meet the assessed needs had been developed well. However, there continues to remain a variance in the quality of care plans especially regarding the actions and guidelines for staff. This was especially apparent in the Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 11 dementia care unit where actions were often a repetition of the statement of need. One care plan stated under ‘Psychological needs’ that the Action by staff to meet the need was ‘Short-term memory loss’. The plans should clearly set out individualised actions and interventions to ensure staff work in a consistent manner. Refer to requirement 1. The home completes a manual handling and fire risk assessment, but all other risk assessments are generic and contain no individualised risk management measures. It is recommended that the home develops a more individualised risk management process focussing on positive outcomes for service users in relation to their specific needs. Refer to recommendation 3. Healthcare records in the home within all the files examined, were clear and up to date demonstrating the healthcare needs are responded to quickly and effectively, issues are referred appropriately and actions required by professionals are followed up. There was evidence that complimentary healthcare needs are addressed including chiropody, dental, hearing and opticians. The home maintains clear records of pressure area care and other wounds and manages these appropriately. It was reported that the home receives good support from district nursing teams and local GP practices. Additionally there is a supportive working relationship reported with the local psychiatric services. Medication issues are well managed within the home. All administration records were up to date, clear and well maintained. The current storage facilities are adequate, but there are plans to re-site the medication room once substantive funds are available. All staff administering medication have received appropriate training and a number of staff have taken additional courses including ASET medication training. Records are maintained of the receipt and disposal of medicines and there is appropriate storage and recording of any controlled drugs used in the home. It was noted that a highlighter pen had been used on the administration records to colour code times of administration. It is advised that this practice should be discontinued. A monthly medication audit is completed by a senior staff member ensuring that no errors or omissions occur and shortfalls are remedied. The privacy and dignity of service users is respected at all times. The inspector spent time in conversation with staff and service users and observed care practices in the home. Some excellent work with service users was observed in the manner that staff interacted with residents and the level of attention to detail. This was particularly noted on the dementia care unit, where staff spent time to explain and talk to residents in a calm and reassuring manner with a very good use of humour in a relaxed manner. The attitude of staff was further strengthened by comments from service users and visitors who consistently reported their caring attitudes, friendly and approachable manner. Residents are consulted about their day-to-day choices. All personal care is provided sensitively and privately. There are no shared bedrooms in the home. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 12 Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users have the opportunity to take part in activities and meet with visitors in a relaxed environment. There is a wholesome and balanced diet provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has begun to make some improvements in the range of activities available for service users, although it is considered that this remains an area of further development. Service users stated that they felt that there is a reasonable range of activities available, but staff members uniformly expressed some frustration at their desire to be able to provide more activities. One staff member said, “I was doing a quiz with some residents a few days ago, when I got called away to help a colleague, but by the time I’d returned the impetus had been lost.” Another staff member said, “It would be nice to have someone just doing activities”. However there was some very positive work noted on the Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 14 Skylark unit. One member of staff noticed that no-one was watching the television and switched it. She then put on some old-time musical hall songs and an impromptu sing-a-long started with a wonderful atmosphere and staff and residents all taking part. The home has begun to keep a timetable of activities, which is sporadically maintained. It is recommended that a dedicated activities co-ordinator is introduced into the home to help arrange and target events and activities with the range of needs of service users in mind. This would enable staff to take part whilst continuing to concentrate on the care needs of service users. Refer to recommendation 4. Visitors are welcomed in to the home at all reasonable times and are made to feel comfortable. There is space for available for visitors to meet in private should they wish. A discussion was held with a relative who stated that she thought that home was “excellent” and that she has enjoyed visiting. She added that the “staff always keep me informed. I haven’t got a bad word to say about the home.” All appointee roles are arranged independently of the service. The home has an access to records policy and documents are maintained in accordance with the Data Protection Act 1998. Residents are encouraged to bring in personal possessions with them and all bedrooms viewed had evidence of this. The menu records in the home were examined and reflected that a healthy, balanced diet is provided with a range of choices available. Nutritional needs and special diets are catered for. There is a cook on duty throughout the week who prepares the main meal and is responsible for ordering. Food stores showed that there is a good range of quality foods and fresh fruit and vegetables available. The majority of comments made about the quality of food were very positive. One person said, “The food is very nice. I have to have it liquidised now, but it is still nice”. Lunch on the Nightingale unit was observed, which was relaxed and unhurried. Staff asked residents if they wanted any help and did not assume that everyone wanted the gravy. One resident was heard to say, “My compliments to the chef, the pie was lovely”. One person said of the food that, “Some days it is better than others, but I can’t complain.” Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users can be confident that their complaint are listened to and acted upon and that they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a clear complaints procedure in place. This is displayed in the home and is included in the service user guide. The procedure encourages concerns, opinions and complaints to be aired and sets out how the service aims to deal with any issues. Complaints are dealt with in a 28 day period and there is a proportionate approach. The home aims to deal with any concerns in an informal way in the first instance, but there are formal processes should an outcome not be satisfactorily reached. Service users all confirmed that they felt able to raise their concerns if they had any and knew who they should approach. Complaints are recorded and any actions monitored. There has been 1 complaint since the last inspection, which was lodged with both the home provider (KCC) and the Commission for Social Care Inspection. An internal investigation is currently being held and the outcome of this is awaited. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 16 There are clear policies and procedures in place relating to adult protection and prevention of abuse. Staff are provided with training in relation to these issues through the induction process, additional training and NVQ. Issues of abuse were discussed with some staff who demonstrated a good working knowledge of the topic. There have been no Adult Protection alerts. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. Service users live in a safe and well-maintained environment and the home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has had the benefit of some additional investment in the premises over the past year responding to a number of issues raised through previous inspection processes. The environment is set out over a single floor and is accessible to service users. New carpets have been laid in communal areas and vinyl flooring replaced in identified bedrooms. Lighting has been replaced in communal areas and redecoration has taken place in areas of the building. The Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 18 home is awaiting funds to continue to develop a new medication room. There is a kitchenette in each wing both of which are showing the signs of age and would benefit from being replaced to improve the ambience of the lounge areas. Refer to recommendation 5. New large plasma televisions have been installed in both main lounges. The gardens surrounding the building have been well-maintained and there is sufficient outdoor furniture for residents to enjoy sitting outside. The home also has quiet rooms for people to meet in private. There is also a designated smoking area. The kitchens are adequate for the needs of the home and received a clean food award from the Environmental Health Officer. The home meets the requirements of the fire safety department. The home was clean and hygienic at the time of the inspection with no unpleasant odours apparent within the building. There are policies relating to the control of infection and the laundry facilities are adequate for the needs of the home. Hand washing facilities are appropriately sited throughout. There are four sluice rooms in the building, which would benefit from being updated in the near future. The sluice systems are old-fashioned and staff find them cumbersome and difficult to use. Refer to recommendation 5. It was reported that the home complies with the Water Supply regulations 1999. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. There are suitable numbers of appropriately trained and competent staff on duty at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Duty rotas accurately reflected that there are suitable numbers of staff on duty at all times. The home is split into two units and there are 3 carers on duty in each unit throughout the day. They are supported by 1-2 Team Leaders during the day with the manager working between the hours of 9-5pm as a general rule. At night time there are 3 carers on duty for the home and a Team Leader sleeping-in for emergency assistance if required. The organisation has an effective on-call system for advice should any untoward occurrences happen outside of normal office hours. The care team are supported by a number of ancillary staff including an administrator, cooks, cleaners and maintenance men. The inspector spent time talking to 5 of the carers on duty and 3 team leaders during the course of the site visit, all of whom demonstrated a good Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 20 understanding of the complex needs of service users as a group and as individuals. Staff were observed to interact and support residents in a positive and enabling manner. All service users and visitors spoken to reported the excellent quality of care that they have experienced. The home is working extremely well to ensure that all staff achieve at least an NVQ level 2 qualification in care. The home currently exceeds the 50 NVQ target and it was reported that nearly all the staff have at least enrolled on an NVQ course. Three staff personnel files were examined for a range of care and ancillary staff. All recruitment records were up to date and well organised. Personnel files contained two written references, completed application forms, proof of identity and evidence of CRB and POVA checks. Training records examined showed that the majority of staff have received all mandatory training and updates. There is a rolling programme of updating training needs identified through Personal Professional Action Plans. KCC provides a comprehensive in-house training programme and monitors staff training needs. Staff have now had the opportunity to attend Dementia care training and other courses relating to mental health needs and the specific needs of service users. All staff have also attended Adult Protection courses. There is a competency based induction programme in use within the home, which all new staff work through during their probationary period. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. The home has an accountable management structure with good health and safety practices. However there is not a registered manager in place and further work is required to develop quality assurance processes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an acting manager currently in place who was not present at the time of the site visit due to training commitments. She has had a number of years of experience as a deputy manager within KCC homes, however this is her first Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 22 managerial appointment. It was reported that she has achieved her NVQ level 4/ RMA. The previous registered manager retired in August 2006 and the current manager has been in place since then. Staff reported that she has a positive management style and are looking forward to a period of managerial stability. It is required that the organisation proposes a manager for Registration with the Commission for Social Care Inspection. Refer to requirement 2. The home has some well-established Quality Assurance processes including regular Regulation 26 monthly monitoring visits conducted routinely by a senior manager. These visits address all key areas of service provision including auditing of records, discussion with service users and staff. Reports of these visits are retained on file for inspection. There remain areas for development however, including annual satisfaction and feedback questionnaires for service users, relatives, staff and professionals. These responses should then be formulated with an annual report showing an action plan to address any perceived or reported shortfalls. Refer to recommendation 6. The home also has a number of internal audit and quality checks including medication and health and safety monitoring. The home provides a safekeeping service for resident’s money and valuables. All appointees are independent of the home. Financial records were examined and were seen to be well maintained and accurate. Records relating to health and safety issues were examined. Policies and procedures are in place relating to safe working practices and staff undergo all required training in respect of these issues. Fire safety logs were up to date and well maintained. The home also had certificates for the maintenance of services including electrical wiring, gas safety and PAT tests amongst others. Environmental risk assessments are in place and updated as required. Accident records are maintained and reported appropriately. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 01/07/07 2. OP31 24 Individual service user plans need to clearly identify the needs and actions required by staff to demonstrate effective and consistent delivery of care and support. The home needs to appoint a 01/06/07 manager who progresses through the fit person process with the Commission for Social Care Inspection to become Registered Manager. 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. Refer to Standard OP1 OP2 Good Practice Recommendations The service user guide and statement of purpose should be updated and reviewed to provide clear, accurate and easy to read information for prospective service users. Contracts should be signed by the service user and/or the nominated representative where there are issues of capacity to understand the information contained. DS0000037892.V334976.R01.S.doc Version 5.2 Page 25 Sampson Court 3. 4. 5. 6. OP7 OP12 OP26 OP19 OP33 The home should review the use of generic risk assessments and consider introducing an individualised risk management process. To consider introducing an activities co-ordinator into the home focussing on developing and engaging service users in a range of tailored activities. To consider the replacement of the kitchenettes in both main lounge areas and the renewal of sluicing facilities. To develop an annual process of satisfaction questionnaires collated with an annual report with targeted outcomes. Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sampson Court DS0000037892.V334976.R01.S.doc Version 5.2 Page 27 - 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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