Inspection on 08/05/07 for Sandalwood

This inspection was carried out on 8th May 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sandalwood 22/12/05

Sandalwood 27/06/05

Sandalwood 14/12/04

Sandalwood 25/08/04

Sandalwood 14/01/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Sandalwood 81 Almners Road Lyne Surrey KT16 0BH Lead Inspector Helen Dickens Unannounced Inspection 8th May 2007 09:30 Sandalwood DS0000013777.V335327.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 Sandalwood DS0000013777.V335327.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. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandalwood Address 81 Almners Road Lyne Surrey KT16 0BH 01932 568623 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) Welmede Housing Association Ltd Mr Abdool Allim Peeroo Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 30-65 YEARS 22nd December 2005 Date of last inspection Brief Description of the Service: Sandalwood is a large detached bungalow located in the village of Lyne in Surrey. The home is owned and managed by Welmede Housing Association and provides accommodation and care to five gentlemen who have a learning disability. All bedrooms are single occupancy and have a washbasin no rooms have ensuite facilities. Communal areas consist of a large lounge with separate dining area, a good size, homely kitchen and two bathrooms with toilets and two further toilets. There is a large, well-maintained, enclosed garden to the rear of the property and parking for several cars to the front of the building. Fees at this home are £1647 per person per week. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over six hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Mr. Abdool Peroo, represented the establishment. A partial tour of the premises took place. The inspector spoke to all the residents and those staff who were on duty during the day. One returned ‘comment card’ from a relative, and compliments letters to the home were also used in writing this report. Two resident’s care plans and a number of other documents and files, including two staff files, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? A number of improvements have taken place since the last inspection including a new kitchen floor being fitted, and a new washing machine, tumble drier and cooker have been purchased. The tiles in one bathroom which needed repair have also been attended to. The home had its first ever quality audit in December 2006, and the manager said this format will now be used elsewhere in Welmede homes. The manager is just about to introduce the new food handling risk assessment pack following some training with environmental health. Staff are having person centred planning training, and the manager has devised a health action plan format which will be used for resident’s health needs. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 6 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. Sandalwood DS0000013777.V335327.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 Sandalwood DS0000013777.V335327.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): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective resident’s needs were assessed prior to admission to Sandalwood. EVIDENCE: The previous inspector noted that the Community Mental Health Trust provided the initial assessments and that these were contained within resident’s files. These residents have lived at Sandalwood for between 5-10 years. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans set out resident’s needs and they are encouraged to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Resident’s care plans reflect their needs and the two sampled had had each aspect reviewed in the last 6 months. A third care plan was partially examined and this too had been recently reviewed by the home. Care plans set down resident’s needs with regard to personal and other support, and guidelines for staff on dealing with challenging behaviour. Resident’s have limited involvement in their care plans due to their special needs, and the registered manager said these plans are compiled with input from key workers, care managers and relatives where possible. The registered manager also said that Surrey residents at the home do not get annual reviews from Surrey Social Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 10 Services care mangers, only the Kingston social services clients are given these reviews. The residents were unable to speak with the inspector but from observation of routines during the inspection, and discussions with the staff and manager, residents did have some opportunities for decision making. For example there is no set time for getting up and the manager said residents are offered a drink in their rooms and can then start getting up in their own time. The registered manager said that breakfast items are offered to residents so that they can choose, for example, if they prefer bread or toast. On arrival at the home residents were enjoying a cooked breakfast of omelettes, prepared by one of the staff. One of the relatives had noted on the home’s questionnaire that their relative at Sandalwood had an excellent quality of life. Risk assessments were noted on the files sampled. A number of areas were covered including being near water, eating too quickly and various activities such as horse-riding and being in the garden. The risk assessments sampled did not appear to have been up-dated recently though the manager said they had been looked at during each resident’s review. He was asked to ensure that the date of the last review for each risk assessment be clearly documented and signed. Some additional risk assessments regarding particular areas in the home are discussed under Standard 38 at the end of this report. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to take part in activities and are supported to be part of the local community. Family relationships are encouraged and residents are treated respectfully. Residents are offered a healthy diet. EVIDENCE: The registered manager said he encourages residents to participate in activities outside the home as this gives them something to look forward to and they all enjoy going out. Currently there are a variety of activities on offer including swimming, horseriding and attending the snoezelen at Geesemere day services. Residents are also encouraged to help in the home within their abilities and one resident was observed helping to clear the table after breakfast. Some are also able to take their laundry to the laundry room, and others can help clean in their bedroom. The residents living in the two bedrooms inspected, both had their own televisions and music. A third Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 12 bedroom was more basically equipped and the registered manager said that was to meet the needs of that particular resident. Residents at this home are part of the local community and are well known at the local farm shop and, according to the last report and the home’s audit, to the local milkman who comes in once a week for a cup of tea. The home supports the local recycling arrangements and a number of different items were being collected outside the front door. They also use local facilities such as health services, the swimming pool in Woking as well as local pubs and takeaways. Residents are encouraged to have family and friendship links and some positive comments were received by the home from relatives in the way of thank you letters, and returned questionnaires. Resident’s files showed staff had a good knowledge of resident’s needs with regard to support from their families and they encouraged this, including taking residents to visit family members on occasions. Residents can choose to be alone or in company and one resident’s file sampled clearly documented that this resident preferred their own company. During the day it was observed that they were able to be alone in their room when they wished. Staff were observed to interact well with residents and treated them respectfully. Residents can access the grounds of the home which consists of a very large back garden with summer house and gazebo, and tables and chairs. Residents at this home need supervision at all times and if they choose to go out into the garden staff always accompany them. The home has its own pet rabbit which some residents help to feed. The registered manager said the home follows the principles in ‘Valuing People’ and the induction of new staff covers ‘O’Briens Five Service Accomplishments’, both of which promote the dignity of residents and their right to respect. Residents were enjoying freshly made omelettes for breakfast on the day of the unannounced inspection. The menus were sent in to CSCI as part of the pre-inspection questionnaire and noted to be varied and contain mostly homemade food options. The registered manager said they do not buy pre-prepared meals. There is a weekly take-away evening and for this they use the local fish and chip shop, or order a pizza. Residents help with the shopping and use the local farm shop and local butcher where possible. The residents have input into the menus by choosing specific items they like and key workers use their knowledge of resident’s likes and dislikes when drawing up the menu. The home has some tomato plants and a grow bag outside, to encourage resident’s involvement in the garden. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 13 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 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare support needs are well documented and arrangements for the administration of medication are good. EVIDENCE: Resident’s care plans document their personal support needs and staff were observed to be attentive to resident’s needs throughout the day. As residents are only able to have limited input into their care plans, the manager said that their needs with regard to personal support had been worked out using input from relatives and key workers, and from knowledge built up about the residents who had all lived at the home for some years. On both resident’s files sampled, the health care assessments had been updated within the last year. Special physical and emotional health needs were documented, including strategies for dealing with challenging behaviour. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 14 Input from health specialists such as the psychiatrist were also noted. One resident had had extensive dental treatment and this was clearly set out, together with monitoring arrangements for their ongoing dental care. Medication is well organised by staff at this home; no residents are selfmedicating. A sample of two resident’s medication administration records were looked at for the previous month and no unexplained gaps were found. The manager said that the system for ensuring all medication was given as prescribed was that each staff member administering medication checked to make sure the last dose had been properly signed for. The community pharmacist last inspected their medication administration arrangements a year ago and the manager was asked to chase up the next visit. No adverse comments were made at that time and it was noted that all staff had been trained to the required level. The manager was currently up-dating the list of staff signatures of those trained to give medication. He was also asked to get written guidance on the use of ‘as required’ medications for residents, to ensure all staff were administering these in a consistent way. Though some guidance existed for some of these medications, more work needed to be done and the manager agreed to discuss this with resident’s GPs. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 15 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 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be taken seriously and they are protected from abuse. EVIDENCE: There have been no complaints at this home since the last inspection though a number of written compliments have been received. There is a very userfriendly complaints procedure for residents and this has been up-dated with the new CSCI Oxford address. One written comment from a relative said that ‘…any concerns are acted on immediately’ by the staff. The home has its own policy on the protection of vulnerable adults and a copy of the latest Surrey county-wide procedures. New staff members covered this subject as part of their induction and two staff files sampled had training certificates to show they had been on a separate course. Some staff need a refresher course and the manager had identified that this was available on the Trust’s very comprehensive list of training courses for the coming year. The manager also stated that following the report into the poor care of people with learning disabilities in Cornwall, the Surrey Primary Care Trust have appointed a lead person to monitor the delivery of care in group homes. This person reports directly to the Trust’s Board. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 16 Two resident’s financial records were sampled and their cash boxes found to contain the exact amount of money recorded in the cash book. Receipts were also kept for any money spent. Two issues were raised with the manager regarding the purchase of a summer house and the way SKY TV is funded; the inspector will seek advice on both matters and advise the manager as necessary. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 17 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 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Sandalwood offers a homely environment which is clean and hygienic throughout. Some decorative shortfalls need to be remedied to meet these Standards in full. EVIDENCE: Sandalwood offers a homely environment for residents who also have access to the very large well-kept garden. Residents were seen to move about as they wished though it was noted most resident’s bedrooms were locked during the afternoon and had to be unlocked when they agreed to show the inspector their rooms. Staff said this was to prevent unauthorised access by one of the residents. The home is nicely furnished with furniture, upholstery and appliances which are domestic in character. Staff do the cleaning themselves and the home was Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 18 clean and fresh throughout, with no unpleasant odours, despite the high incidence of incontinence among residents. A number of decorative shortfalls were noted however, especially marks on the walls and skirting in the hallway, and some bedrooms, and a stained radiator cover in one bathroom. Bathroom tiles which needed replacing, noted at the last inspection, have now been done, but the boxing around the pipes in one toilet, also mentioned at the last inspection, has still not been completed to a reasonable finish. In addition, a broken radiator cover noted at the last inspection was broken again and the manager was asked to review arrangements for making this radiator safe for residents. The following day, the manager made contact with CSCI to say someone had been out to look at the radiator already. The bathroom cabinet contained disinfectant which could have posed a risk to residents, and water temperatures were lower than recommended limits. New Requirements will be made on these matters. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 19 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): 32,34 and 35 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and well-trained staff, though recruitment practices need further work, for example regarding seeking a full employment history for all staff. EVIDENCE: The number of staff on duty at the home has been calculated with the care services manager and is based on the needs of current residents. On the morning of the inspection they were one member of staff short, but residents were well looked after and were out for most of the morning at the local day centre where the manager said extra assistance was available. By the afternoon, all staff were present who were down on the rota. When asked about weekend staffing, the manger said neither he nor his deputy are allowed to work at weekends at the moment because of the financial implications to the Trust. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 20 Staff anticipated resident’s needs and residents were seen to turn to them for assistance. The residents are all white British but the staff are more ethnically diverse. The manager was asked if this had presented any specific problems and he highlighted one or two issues which had been dealt with as they arose. For example staff had not initially been knowledgeable on traditional British cooking but this had since been remedied. Currently only 33 of care staff have NVQ Level 2 but the manager said that it is likely to be above 50 (as set down in Standard 32) by the end of the year as those currently taking the course complete it. Recruitment files were securely kept and in relatively good order. A list of CRB numbers was kept on the computer to show that staff had had the relevant checks. The manager was asked to add an extra column to the list to show if a pova list check had been carried out. The home’s application form asks for employment history for the last ten years when it must ask for a ‘full’ employment history. One staff file did not have an application form as the manager said that this staff member had been there for many years. The manager was asked to ensure that all staff files contained the correct recruitment information as set out in Schedule 2 of the Care Homes Regulations 2001 (as amended). There is a comprehensive training programme for the year provided by the Surrey Primary Care Trust and the manager was aware of which courses were suitable for care home staff. He said things had improved with regard to training as last year budgetry constraints within the Trust meant that training was not available. Refresher courses are also on the current programme, for example on moving and handling, and on vulnerable adults procedures. Staff certificates were on file for the training staff had already completed but there was no central list as yet; the manger said he was working on this. This will need to be completed so that a training needs assessment can be carried out for the team as set down in Standard 35.6. The induction arrangements for the most recent staff member were sampled and found to cover relevant topics, however, the home should have a more comprehensive plan for new staff based on a recognised model, for example the Common Induction Standards, and the manager said he would look into this. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 21 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): 37,39 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents at Sandalwood benefit from a well-run home. Quality assurance processes continue to improve though more work needs to be done, for example on gaining the views of residents and other stakeholders, and having an annual development plan. The health, safety and welfare of residents are promoted at this home. EVIDENCE: The current registered manager has been at Sandalwood since it opened ten years ago. He has a Level 1 nursing qualification and has passed the Registered Managers Award. He continues to up-date his own training and has recently done courses in interviewing (for staff recruitment) and HACCP Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 22 training (with environmental health on the new food handling regulations). The manager was observed to have a good rapport with staff and residents alike, and was very knowledgeable on resident’s needs and their family relationships. An ex-member of staff who had called into the home was very complimentary about how the manager had helped him personally to develop his career, and as a consequence he had now been promoted and was working in another Welmede home. The manager is currently involved in some quality audit work at The University of Surrey looking at care practices. There are a number of quality assurance processes in place at this home including Regulation 26 visits, and questionnaires which are mainly completed on behalf of residents by their relatives. The manager, in association with Welmede, has just piloted the first ever quality audit of Sandalwood, in December 2006. The manager also prepares an annual report. The manager does not currently have an annual development plan and this may come out of the work done in December 2006. However, the home must have regard to the items set out in Standard 39 including ensuring that residents and other stakeholders views are taken into account. Welmede do a two yearly health and safety audit in each property and Sandalwood was last audited at the end of 2005. The annual fire safety risk assessment was also done in 2005 and is therefore overdue; the manager said this is now scheduled to coincide with staff having fire safety training. A number of health and safety certificates were sampled including the gas safety check, a boiler check, and the electrical installation certificate. The last environmental health visit was in December 2006 and the manager said the recommendations from that report had now been met. The manager has also been on a course relating to the new food handling regulations and the ‘Safer Food Better Business’ arrangements will be introduced to Sandalwood within the next three months, following a further meeting between the manager and the environmental health officer. On the day of the inspection the hazardous substances cupboard was safely locked. However, there was a small bottle of disinfectant left in the bathroom cabinet which may have posed a risk to residents; the manager removed this immediately. There were also items in the laundry room such as an open box of washing powder and liquid softener which may have posed a risk if ingested. The manager was asked to complete a written risk assessment and to take any actions which came out of this. In addition, it was not clear what arrangements were in place to protect the home from legionella. In addition to an annual water bacteriology check which is already done, the home should have arrangements in place to prevent legionella in the first place. A Health and Safety Executive leaflet on this subject was given to the manager and he was asked to get further advice. It was noted that the thermostatic controls on water outlets were cooling water to below 30C in some cases and the manager was asked to take advice on this too. Sandalwood DS0000013777.V335327.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 2 X X 2 X Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 08/06/07 2. YA24 3. YA34 4. YA35 Written guidance on the use of ‘as required’ medications must be sought and clearly documented to ensure all staff are administering these in a consistent way. 23(2)(b)(d) The wooden boxing around the pipes in one toilet, has still not been completed to a reasonable finish. Outstanding from 31/01/06 In addition, a broken radiator cover noted at the last inspection was broken again and needed to be mended or replaced. Outstanding from 31/01/06 19 All staff files must contain the correct recruitment information as set out in Schedule 2 of the Care Homes Regulations 2001 (as amended). 18(1)(a) In order to ensure that at all times suitably qualified and experienced persons are working at the home, a central list of staff training and skills must be compiled, and a training needs assessment carried out as set down in DS0000013777.V335327.R01.S.doc 08/06/07 08/06/07 08/06/07 Sandalwood Version 5.2 Page 25 Standard 35.6 5. YA39 24(1) An annual development plan 08/07/07 must be produced for the home, including items listed in Standard 39, and with particular reference to taking into account the views of residents and other stakeholders. Risk assessments on the 14/05/07 laundry room, and on the storage of liquids in the bathroom cabinet must be carried out and any necessary action taken. Advice must be taken and 08/06/07 suitable procedures introduced within the home, to prevent the spread of legionella. 6. YA42 13(4)(a) 7. YA42 13(4)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations A more comprehensive induction should be introduced for new staff based on a recognised good practice model such as the Common Induction Standards. Sandalwood DS0000013777.V335327.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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