Inspection on 27/09/06 for Sandbourne House

This inspection was carried out on 27th September 2006.

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

Other inspections for this house

Sandbourne House 23/09/09

Sandbourne House 13/09/07

Sandbourne House 25/01/06

Sandbourne House 26/09/05

Sandbourne House 23/03/05

Sandbourne House 08/02/05

Sandbourne House 18/02/04

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 Sandbourne House 1 Sandecotes Road Parkstone Poole Dorset BH14 8NT Lead Inspector Stephanie Omosevwerha Key Unannounced Inspection 27th September & 3rd October 2006 10:00 DS0000004080.V312405.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 DS0000004080.V312405.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. DS0000004080.V312405.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandbourne House Address 1 Sandecotes Road Parkstone Poole Dorset BH14 8NT 01202 742284 F/P01202 742284 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Helen Vivien Somerville Mrs Janet Lesley Young Miss Lisa Toms Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000004080.V312405.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named service user (as known to the CSCI) prior to their eighteenth birthday. 25th January 2006 Date of last inspection Brief Description of the Service: Sandbourne House accommodates 8 adults, with a purpose of providing care and support to residents who have a learning disability. It is owned by Mrs Helen Somerville and Mrs Janet Young. The registered manager is Miss Lisa Toms and she works in the home full time. The home was first registered in 1997, and the majority of the residents have lived there since it opened. It is a large family style house in a residential area of Lower Parkstone. The shopping areas of Parkstone are walking distance away and there is accessible public transport to the towns of Poole and Bournemouth. The house comprises of a lounge, separate diner and kitchen, bathroom, separate WC and each resident has their own bedroom. 4 of the bedrooms have en-suite facilities. Through the kitchen is an office, staff sleeping in room, shower and toilet. The home has a well-kept garden. The home is staffed 24 hours of the day, with at least two staff on duty when the service users are at home, except at night when only one sleep in member of staff is needed. The home has recently agreed additional funding for some service users to provide a day care service, three days a week beginning in October 2006. Current fees provided on 03/10/06 are between £500 and £600 per week, which is inclusive of day care provision as stated above. Fees do not include personal items such as toiletries, hairdressing, chiropody, transport and magazines. For further information on fee levels and fair terms of contracts you are advised to referred to the Office of Fair Trading website www.oft.gov.uk. The home keeps copies of all inspection reports that are available in the office and can be seen by service users, relatives and professionals at their request. DS0000004080.V312405.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection of the home and took place over a total of 7 hours over the course of 2 days (the 27th September and 3rd October 2006). It was carried out as part of the planned inspection programme for care homes undertaken by CSCI and to address the requirements and recommendations made at the previous inspection. This inspection was a key inspection and therefore, assessed all identified key national minimum standards for care homes for adults (18-65). During the inspection all communal rooms were seen and all service users bedrooms were viewed. The registered manager was present throughout the second day of the inspection and assisted the inspector with checking various records such as care plans, service user files, financial records, risk assessments and staffing records. A sample of policy and procedures were also read such as policies for adult protection. The inspector also had the opportunity to speak with 3 residents both on an individual and collective basis and 2 members of care staff. Additional information received prior to the inspection was taken into account including the pre-inspection questionnaire completed by the manager, 7 service users’ surveys, 2 relatives’ surveys and 4 professionals’ surveys. Comments received about the service were very positive such as “an excellent, well run home” and “I wish all homes were as nice as this one”. Further evidence was also provided from previous inspection reports and reports from monthly monitoring visits carried out by the responsible individual. What the service does well: Sandbourne House provides a comfortable and homely environment that clearly reflects the lives of the people who live there. The home has comprehensive care planning systems in place ensuring staff have good information about service users care needs. Observations made during the visit indicated that service users shared good relationships with staff, and that staff were knowledgeable and understanding of each person’s needs and preferences. Identified risks are well managed with staff able to balance the need to protect service users against that of promoting their independence. Sandbourne House has good access to the local community and service users regularly go out and are provided with an excellent range of social, educational and leisure activities. Routines and mealtimes in the home are flexible and reflect service users’ choices. Service users have good access to local health care services and professionals promoting their physical and mental well-being. The home works hard to involve families and friends in the life of the home supporting and encouraging service users personal relationships. DS0000004080.V312405.R01.S.doc Version 5.2 Page 6 The manager has developed an excellent quality monitoring system that has been really effective in promoting positive changes in the home based on feedback received from service users. For example the setting up of a new day service to provide service users with more individual time and choice. Sandbourne House has been assessed through previous inspections as a service, which consistently achieves good outcomes for service users. It has a good track record of compliance with Regulations and National Minimum standards. What has improved since the last inspection? What they could do better: As a result of this inspection one requirement and one recommendation have been made. The home is currently making progress towards establishing a workforce that achieves nationally recognised care qualifications but is currently under the required target of 50 . It was recommended that the home keep a copy of all service users’ contracts to ensure they can provide evidence that these are in place. DS0000004080.V312405.R01.S.doc Version 5.2 Page 7 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. DS0000004080.V312405.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000004080.V312405.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures ensure due consideration is given to prospective service users needs and they have excellent opportunities to “test” out the service before agreeing a permanent placement. EVIDENCE: There had been one new admission to the home since the previous inspection. The individual file for this service user was case tracked and there was evidence that a care management assessment and plan prior to the placement being agreed. The home also carries out there own initial assessment that details service users personal care needs, life skills, health and communication and funding/benefits. The manager had developed an admission checklist to record details of introductory visits and evidence that the service user had been given all relevant information about the home such as the service user guide and CSCI inspection reports. The checklist provided further opportunities to assess how the prospective resident interacted with other residents and staff. There was a recommendation made at the previous inspection that service users and/or their representative should agree a contract prior to moving into the home. The inspector saw evidence that contracts were in place in an DS0000004080.V312405.R01.S.doc Version 5.2 Page 10 accessible format for most residents. However, whilst it had been recorded that the newest resident had been given a contract there was no evidence of a contract on their individual file. The manager told the inspector that she thought that the social worker had been given the contract to look at and had not yet returned it. It is recommended, therefore, that the home retain a copy of the service user’s contract on their individual file. DS0000004080.V312405.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans are in place that are regularly reviewed to ensure staff are fully informed about all aspects of service users care. Staff promote service users choices ensuring they are able to make decisions about various aspects of their daily lives. The home has good systems for managing risks effectively balancing service users rights to independence and safety. EVIDENCE: A sample of 2 service users plans was case tracked as part of the inspection. Evidence from previous inspections showed that care plans were in place for all service users setting out their needs and how these are to be met by the home. Care plans cover a whole range of service users needs such as health, personal care, work/occupation, mobility, domestic tasks, social life, financial, DS0000004080.V312405.R01.S.doc Version 5.2 Page 12 night care and personal relationships. These address the service users needs and the staff tasks that are required to meet them. There was evidence that plans were regularly reviewed and up-dated to reflect any changes in service users care. Further guidance was available to staff concerning managing specialist needs such as challenging behaviour. There was evidence that service users were consulted on a regular basis and encouraged to make decisions about their lives. Regular residents’ meeting were held in the home and the inspector was shown the minutes of these. Issues such as outings, staffing, health and safety and complaints had been discussed. Residents told the inspector they were supported to make decisions about their lives on a regular basis, e.g. spending their money, going out on activities and their daily routines. Observation of practice demonstrated staff actively promoted service users decision making encouraging them to make choices independently where possible. All service users have their own bank accounts and are supported to manage their own finances. The registered proprietor is currently appointee for 3 residents. A sample of service users’ financial records was checked as part of the inspection and these were found to be accurate with details of all transactions being recorded and receipts of all purchases kept. Risk assessments were seen for each service users. These were appropriate and well documented. Where restrictions were necessary there were clear reasons why. For example where service users needed support with medication, going out on their own, holding their own keys. The assessments were based on promoting skills where possible such as working towards going out unaccompanied. Observation during the inspection showed how risk management procedures were put into practice when an incident occurred during the inspection. The manager implemented procedures immediately to promote the safety of service users and ensure that the incident was resolved as quickly as possible. DS0000004080.V312405.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident has a suitable weekly activity programme that varies according to individual need. Recent investment has meant the home has been able to set up its own day care programme to offer residents’ more choice about what they do during the week. Service users regularly access the facilities in the local community and participate in a wide range of social and leisure activities. Staff work hard to involve families and friends in the life of the home promoting and encouraging service users personal relationships. Individual rights are respected and responsibilities in the home are clearly understood and recognised by the service users. The home provides a balanced and varied selection of food that meets service users tastes and choices. DS0000004080.V312405.R01.S.doc Version 5.2 Page 14 EVIDENCE: All service users were out at their usual day time activities at the beginning of the inspection except one service user who had stayed home as they were not well enough to attend their usual daytime activity. Individual care plans showed that service user attended activities including local day services, college courses, adult education classes and work placements. Two service users came back from their activities at lunchtime and discussion with one of the residents confirmed they were happy with their weekly programme. The manager told the inspector the home had recently negotiated funding to begin their own day time programme in the home 3 days a week. This would provide service users with more choice with opportunities for them to have one-to-one time and learn new skills. An additional member of staff had been specifically recruited to work with service users during these 3 days. There was further evidence that service users had good links with their local community and residents told the inspector that they used the local shops and post office. Observation during the first day of the inspection showed a member of staff taking a resident out to the local shops for the morning. Another resident was able to access public transport independently to travel to local shopping centres. Service users family details are recorded on their individual files. The manager told the inspector the home welcomes visits from friends and families and often facilitates these by providing transport if necessary. The inspector received two completed relatives surveys prior to the inspection that indicated they were able to visit, one stated “staff are always happy and welcome me into the home”. Service users are encouraged to attend social events and develop new relationships with other people and they attend outside clubs and social events. Service users reported that their privacy was respected and that they could spend time alone in their rooms or socialise in the communal areas of the home. Responsibilities for household chores were clearly set out in individual plans, e.g. laying the table, making simple snacks, making drinks, washing up and using the washing machine. Residents explained they generally took care of their own rooms and also participated in domestic tasks around the home e.g. hoovering. The inspector observed one resident doing their laundry during the inspection and they were encouraged to do this independently with appropriate support when required, another service user was looking forward to helping with the evening’s meal preparations. A sample of menus was viewed as part of the inspection. These were found to be varied and nutritious. The manager said residents were involved in the DS0000004080.V312405.R01.S.doc Version 5.2 Page 15 planning of the menu and picture formats were used to assist service users in making choices. Service users told the inspector they enjoyed the food in the home and were able to make choices and help with meal preparation. DS0000004080.V312405.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care was carried out sensitively in a way that promoted service users choice and independence. Service users had good access to healthcare services ensuring that all their physical and emotional needs are well met. The procedures for administering medication in the home are good ensuring safe practice and the well-being of service users. EVIDENCE: Personal care needs were clearly documented on individual care plans. These varied with some residents being independent only requiring occasional verbal prompting to those residents that were more dependent on staff assistance. There was an emphasis on supporting service users to do what they could e.g. “X can take her shoes off and put clothes into wash basket”. Residents indicated that they received the care they needed and they were treated with dignity and respect. Observation of practice in the home showed staff DS0000004080.V312405.R01.S.doc Version 5.2 Page 17 undertook personal care tasks in a sensitive way respecting individual’s privacy. Staff spoken with during the inspection demonstrated a good understanding of the personal and healthcare needs of service users living in the home. Health care needs were clearly set out in service users’ care plans taking into account both physical and mental health needs. Records showed service users had good access to healthcare services such as attending clinics for hearing or breast screening and access to healthcare professionals such as dentists, opticians and chiropodists. There was evidence of liaison with other professionals such as community nurses/psychologists to provide further guidance for staff such as suggestions of activities to promote positive behaviour. Good records were kept of service users current medication and further information about health conditions such as epilepsy was available in the home. The home has a written policy and procedure for the administration of medication that is specific to Sandbourne House. Risk assessments have been carried out on all service users’ abilities to administer their own medication and the level of support they need. Medicines are kept securely in a locked cupboard. A monitored dosage system is used and records were checked and found to be accurate and up-to-date. The manager has overall responsibility for ordering and checking medication and the quantities received are recorded on the MAR sheets to facilitate monitoring. Details of all medications prescribed, what it is for, drug descriptions and side effects are clearly listed for members of staff. All staff receive training in the safe handling of medication prior to administering it to residents. DS0000004080.V312405.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were offered regular opportunities to raise concerns ensuring these could be quickly dealt with and acted upon. Further guidance and training has provided staff with a better knowledge of adult protection procedures promoting the protection of service users in the home. EVIDENCE: The inspector was shown a copy of the home’s complaints procedure that is also available in a format suitable for service users. Service users are offered further opportunities to raise any concerns and there was a regular item for discussing complaints at the residents meeting, which was evident on the minutes seen by the inspector. The home keeps a complaint log, however, no complaints have been received concerning the service. The home’s policy on abuse has been amended since the last inspection to incorporate the suggested amendments and provide more comprehensive guidance to staff. The manager has also arranged for all staff to update their training on adult protection issues. There have been no adult protection concerns in the home since the last inspection. DS0000004080.V312405.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Continued investment in the environment ensures that Sandbourne House is well maintained and continues to provide service users with a comfortable home. The standard of cleanliness is good providing service users with a hygienic environment. EVIDENCE: A tour of the premises was carried out as part of the inspection and all communal areas were viewed and all resident’s rooms were seen. Communal rooms consisted of a lounge, dining room and kitchen. They were seen to be clean and bright and decorated in an attractive, homely way. Since the previous inspection the lounge has been re-painted and new windows and door have been fitted in the conservatory area making it more inviting. Service users were observed to have unrestricted use of all communal areas throughout the inspection. DS0000004080.V312405.R01.S.doc Version 5.2 Page 20 Bedrooms had been individually personalised and residents confirmed they had been able to choose the décor. Two bedrooms had been re-carpeted since the previous inspection. There was plenty of space for personal items and service users told the inspector they like their rooms. On the day of the inspection the home was found to be clean and tidy. There is an infection control policy kept in the home and staff have undertaken infection control training. DS0000004080.V312405.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is making progress towards establishing a workforce that achieves nationally recognised care qualifications and service users have confidence in the skills and experience of the care workers. Robust procedures are in place to ensure newly recruited members of staff are appropriately vetted safeguarding the welfare of service users living in the home. Satisfactory training is provided to ensure staff are aware of appropriate practices in the home and they are equipped with the skills they need for working with the service users. EVIDENCE: The home currently employs 8 members of staff. Staff records showed that most members of staff had previous experience of working in the care sector and some had considerable experience of working with adults with learning disabilities. Staff spoken with told the inspector they enjoyed their work and residents also spoke positively about the staff. Observations made during the DS0000004080.V312405.R01.S.doc Version 5.2 Page 22 visit indicated that service users shared good relationships with staff, and that staff were knowledgeable and understanding of each person’s needs and preferences. The home currently has no staff with a NVQ qualification and the manager is aware of this and is making progress towards the target of 50 qualified staff with two members of staff currently working towards NVQ Level 2, a further two members of staff have undertaken the LDAF induction and foundation units. The home’s recruitment procedure consisted of placing an advert, sending out application forms and job descriptions, giving prospective candidates the opportunity for an informal visit to the home to meet the residents who were then able to give feedback on the applicant. Interviews were then carried out with reference to equal opportunities. Successful applicants were then appointed subject to satisfactory references and a clear enhanced CRB and POVA check. A sample of 2 staff files was viewed. All records were complete with relevant references and CRB checks in place. Staff received terms and conditions and were appointed subject to a 3 month probationary period. There was evidence that a review was carried out after 3 months and the employee was then either made permanent or the probationary period extended if necessary. Copies of the General Social Care Council’s codes of conduct and practice were available to all staff. The manager has responsibility for organising and planning training in the home. There is an in-house programme that provides staff with certificates in health and safety, first aid, fire training, infection control, management of medication and challenging behaviour. Following recommendations at the previous inspection the manager has liaised with the Borough of Poole to provide additional training to staff including adult protection and diversity training. The manager provides staff with additional information on learning disabilities, which is available in the home for all staff to read. The manager informed the inspector that any additional training would be considered as necessary based on the needs of service users living in the home. An induction package has been set up for new staff that is very comprehensive and based on the latest guidance from Skills for Care. DS0000004080.V312405.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s manager is experienced and qualified and is competently meeting the home’s stated purpose, aims and objectives. The manager has set up an effective quality assurance systems that is based on feedback from service users and promotes further improvements to the service. Improvements had been made to a number of health and safety systems ensuring service users are appropriately protected in the home. DS0000004080.V312405.R01.S.doc Version 5.2 Page 24 EVIDENCE: Lisa Toms is the registered manager of Sandbourne House. She has successfully completed the Registered Managers Award and NVQ Level 4 in care. She previously worked as the deputy manager in the home so has a good knowledge and understanding of the way the home is run and its aims and objectives. There was further evidence that she keeps her training up-todate and since the previous inspection she had completed updates in risk assessment, medication, health and safety and fire training. She is currently undertaking an Assessors course which will enable her to facilitate staff training in the home by undertaking this role herself. There was evidence that the manager had introduced an effective quality assurance system in the home. Residents’ and relatives’ surveys had been carried out on an annual basis. The inspector was shown the annual development plan for the home setting out the targets for the forthcoming year. This had been based on feedback received from the residents. For example, some residents had requested more one to one time in the home. In response to this the manager had negotiated funding to provide a day service in the home so service users could benefit from more individual time during the week. The inspector examined records that showed that the home was meeting the requirements of other agencies such as Dorset Fire and Rescue Service and Environmental Health Department. Certificates were in place demonstrating that equipment and facilities were regularly serviced and maintained. Records of fridge and freezer temperatures were kept and the manager had organised a complete check on all water temperatures by an outside contractor. The manager stated she now intended to carry out regular monitoring of the water temperatures in the home. A fire risk assessment was in place and staff carry out visual checks on equipment. A record of fire drills is kept and these showed the times of these had now been varied as recommended at the previous inspection. The home had clear policies and procedures relating to health and safety practices. The manager confirmed her awareness of relevant legislation and certificates were in place showing staff had attended various training courses in safe working practices. DS0000004080.V312405.R01.S.doc Version 5.2 Page 25 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 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 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 X X 3 X DS0000004080.V312405.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18 Requirement There must be suitably qualified staff working in the care home to meet the needs of service users. (This requirement has been repeated from the previous inspection.) Timescale for action 01/04/07 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 YA5 Good Practice Recommendations It is recommended that the home retain a copy of the service user’s contract on their individual file. DS0000004080.V312405.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000004080.V312405.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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