Inspection on 10/03/08 for Sansigra

This inspection was carried out on 10th March 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sansigra 14/08/08

Sansigra 19/03/07

Sansigra 24/10/05

Sansigra 20/04/05

Sansigra 06/12/04

Sansigra 19/07/04

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 Sansigra High Road Zelah Truro Cornwall TR4 9HN Lead Inspector Alan Pitts Unannounced Inspection 10th March 2008 10:00 Sansigra DS0000009166.V360694.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 Sansigra DS0000009166.V360694.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. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sansigra Address High Road Zelah Truro Cornwall TR4 9HN 01872 540363 01872 540363 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 Ann Penellum Mr Alan Graham Penellum Position Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include one named person outside of the normal age range of the Home. Total number of service users not to exceed a maximum of 8 Date of last inspection Brief Description of the Service: Sansigra is situated in the village of Zelah with easy access off the main dual carriageway to Truro or Penzance. The village has suitable facilities such as a public house. The home has parking, and spacious and pleasant gardens. The property is a large house that has been extended to accommodate eight service users, with the owners also living in the home. The home is well maintained and suitably furnished. Each bedroom in the home is single occupancy with a hand basin provided. Three bedrooms are available on the ground floor, with a walk in shower facility also available on this level. The ground floor is accessible to wheelchair users. Weekly fees range from £293 to £346. There are variable additional charges to service users for petrol when the homes transport is used for outings and not appointments in the community, alcoholic beverages, hairdressing, confectionary, private chiropody, dry cleaning and off-site entertainment. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. Two inspectors carried out this inspection over a period of approximately six hours. We spoke with one resident, the registered manager and her husband, and a member of staff. We looked round the home including the rooms of the people that live there. We inspected the homes’ documentation. We also took into account information provided before the inspection from staff and the Department for Adult Social Care. Overall, the home cannot demonstrate individualised care or an acceptable quality of life for the people that live there. What the service does well: What has improved since the last inspection? What they could do better: Three recommendations identified at the last inspection have not been fully met. These are regarding care planning and the system for recording CRB checks of the staff. The home needs to keep residents and/or their representatives fully informed of charges made. The home could improve the care plans, risk-assessments, and reviews to better demonstrate the quality of life of the people that live there. The home could improve the social/recreational opportunities available to residents, reflecting their individual interests and hobbies. The home could improve the diet offered. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 6 Staffing needs to be increased to reflect the care and social needs of the residents. More must be done to protect the financial interests of residents. 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. Sansigra DS0000009166.V360694.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 Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have not been any new admissions since 2006. Residents and their representatives are not given the information they need to make an informed choice regarding their care provider. The provider is fully aware of the requirement for a proper pre-admission assessment. EVIDENCE: The Statement of Purpose is regularly updated, but this document does not include accurate information about the charges made to residents. The Statement of Purpose currently states that there are no additional charges, and makes no mention of a charge being made for transport. This matter is dealt with in more detail further on in this report. The home has accommodated the same residents for a long time. There is assessment and review information on their personal files to show that their needs are being monitored and reviewed. Sansigra DS0000009166.V360694.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, 9 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is little evidence of residents making informed decisions and taking responsible risks. The evidence indicates that the residents are ‘done to’ and ‘done for’ as opposed to being enabled to do for themselves as much as possible. EVIDENCE: We looked at 50 of the care plans and related documentation. Although there is clear evidence of frequent and regular review of care plans, including the residents’ signature where possible, there is no evidence of family and/or representative or external professionals involvement in care reviews. The care plans give insufficient direction in respect of care needs (e.g. stating “needs assistance with dressing”), rather than specifying the individuals’ capabilities. There is a large print version of the care plan, which starts out written in the first person (from the perspective of the resident “I like…”), but then switches Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 10 to third person and continues to be instruction to staff (“…staff to provide clean clothes and remove dirty ones”) Risk-assessments tend towards being an assessment of care input needed rather than a true assessment of potential risks posed by life activities. The language used throughout the assessments, care plans and reviews focuses on what staff need to do, as opposed to what the resident is able to do. There is little evidence of individualised assessment (all the files inspected showed “staff to provide clean clothes and remove dirty ones”). There is little evidence of residents making decisions in a meaningful way. Daily entries are far too brief (e.g. “shopping”, and “out with Mr Penellum”) to give useful information, and do not show the residents’ involvement in making choices or in taking responsible risks. This was confirmed by Mrs Penellum who admitted she would find it difficult to allow any of the people that live there free and unsupervised access to the garden. The residents personal allowance is included with the home’s fee and is paid directly into Sansigra’s bank account. The registered provider then manages the residents’ allowance, keeping the money securely at the home. Records are kept, but these are not sufficiently detailed (“petrol”, “shopping”), and are not sufficiently supported by receipts. The records show that some residents have a negative balance at the home, in one instance a sum approaching £150, despite the resident having sufficient money in their own bank account. Mr Penellum said that this was because he had not had chance to go to the bank (Sansigra account) to withdraw the residents personal allowance money to top up the balance. This means that the registered provider may be benefiting from interest accrued on the residents’ money being in the home’s bank account, whilst the resident is not benefiting from any interest that might be accrued if the money were in their own account. Disability Living Allowance is paid directly into the residents’ own bank accounts, the books for which are held by the registered provider. The registered provider is appointee for the residents even though it may be possible for an independent agent/family member to fulfil this role. The registered providers charge residents for transport. Mr Penellum told the inspectors that he charges per mile, but there is no evidence of a set rate, nor is there evidence of the charge having been agreed prior to implementation. The charges to each resident vary, but approximate at a total of £400 per month. The registered provider could not show that this charge had been notified to anyone. Sansigra DS0000009166.V360694.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, 17 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is evidence of residents partaking in activities, and engaging with the wider local community. Residents maintain contact with family. The home does not promote independence. There is insufficient evidence of a nutritious, varied, balanced diet. EVIDENCE: One resident has a work placement, though another four are enjoying a gardening course. The immediate community offers only a pub. No evidence was seen of residents accessing facilities such as libraries, cinemas, or leisure centres. One resident attends church when with their family, but none attend from the home. Activities undertaken are predominantly, pub and karaoke and are group focused. There is little evidence of residents pursuing individual lifestyles or interests and hobbies. Residents are registered on the electoral roll, and the Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 12 registered provider said that some do vote. Although there is evidence of residents visiting family outside of the care home, there is no evidence of visitors to the home (other than ‘official’ visitors, such as the inspectors). Although Mrs Penellum said that residents would be free to invite friends to the home there was no evidence of the residents enjoying personal relationships with people of their choice. There is evidence that the residents were asked if they wished to have a key to their bedrooms, and secure storage is available to them. The registered provider’s husband refers to the people that live at the home as “the lads”, despite the fact that some of the residents are older than the registered provider and her husband and the inspectors. One member of staff was observed to interact pleasantly and appropriately with a resident. Residents do not have unrestricted access to the grounds. The registered providers told us that this is because of perceived risks e.g. uneven ground and a fish pond. Mrs Penellum said that she does not plan a menu, deciding on a day-to-day basis what to prepare. Mrs Penellum stated that the residents do receive a hot meal in the evening on weekdays. There is no evidence that the people that live at the home have any input into the menu. The freezer and fridges were seen to be well stocked, though the former predominantly with ‘ready meals’. The menu as it is shows a choice available at evening meal, but there is no record of food provided so there is no evidence to support the assertion that the menu is an accurate reflection of diet. The registered provider took sausages out the freezer for the evening meal on the day of the inspection. The menu is also limited in the variety of foods offered and may not provide a balanced nutritional diet. The following being shown on the menu as the evening meals from 25/02/08: Scrambled egg, spaghetti, tomatoes Beefburger, bap, oven chips Sausages, mashed potato, carrots, gravy Southern fried chicken, duchesse potatoes Fish fingers, oven chips, peas, grilled tomatoes Ham omelette, side salad, bread roll Cold lamb, chutney, baps, sausage rolls Pizza, mixed salad Smoked bacon streaks, sauté potatoes, tomatoes Southern fried chicken, side salad Sausages, potatoes, peas, grilled tomatoes Home made quiche, sauté potatoes, sweetcorn Fish and chips Cold pork, chutney, baps, chips Mrs Penellum told us that every day a variety of sandwiches and soup are available in addition to the above menu, and confirmed that she prepares a packed lunch on weekdays when the residents attend external venues. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 13 Mrs Penellum said that the evening meal is provided between 17:00 and 18:30 hours, with supper being available around 20:30 hours. Supper consists of cake, biscuits, crisps, and tea or coffee. Mrs Penellum said that hot chocolate is available. Breakfast is at 07:15, consisting of a variety of cereals, bread and butter, toast, and tea or coffee. Mrs Penellum said that the residents have free access to the kitchen and food and drink, saying “yes if they want to, but they don’t tend to, they ask if they can”. The registered provider said “I do most of the cooking, the boys help fetching, carrying, and laying the table”. Environmental Health have not inspected recently, though Mrs Penellum confirmed that the home is working towards the ‘safer food better business’ award. Fridge and freezer temperatures are displayed. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support is not flexible and does not reflect residents’ individual capabilities or wishes. The healthcare needs of residents are well met. Residents are generally protected by the homes’ medicine procedures. EVIDENCE: Comment has already been made about the same statement being applied to all the resident files inspected (Standard 2), and the brevity of entries in the daily records. There is little evidence of flexibility in times for getting up/going to bed, though it is recognised that there is sometimes a need for a set time when there is an appointment to attend. There is clear evidence that the residents have ready access to health professionals, and assistance with attending appointments. None of the residents self-medicate. There is only a small number of medicines on the property. The home is using domestic bathroom cabinets for the storage of medicines. The medicines were recently inspected by the supplying pharmacist. The registered provider said that that the pharmacist considered Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 15 the cabinets satisfactory for the medicines stored. There is an appropriate medicines policy and procedure, and a copy of the Royal Pharmaceutical Society publication ‘The Handling of Medicines in Social Care’ was available. The signatures used on Medicine Administration Records are the same ‘P’ for Penellum. This makes it difficult to discern who administered medication as we were told that both of the registered providers and one of their daughters all administer medication. The registered provider stated that she will administer paracetamol without a prescription, but an agreed homely remedies list was not available. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a clear complaints procedure and a complaints log is in place. The home is the subject of a current investigation to ensure the welfare of the residents. EVIDENCE: There is an appropriate complaints policy and procedure, needing only minor amendment to include the Commission for Social Care Inspection Bristol address and contact numbers. The registered provider said that ‘how to complain’ was discussed occasionally at resident meetings, but the minutes of the meetings were not seen. The complaints procedure is not provided to residents in an alternative format, suited to their individual needs. A complaints log is available – no complaints have been recorded. The registered provider stated that she and her husband had attended adult protection training, though certificates of attendance were not seen. The Commission for Social Care Inspection is aware of a current adult protection/safeguarding investigation into practices at the home. Sansigra DS0000009166.V360694.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, 28, 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and safe environment. The home is clean and free of undue odours. EVIDENCE: Sansigra is a detached house in the village of Zelah. It is an impressive property set in its own grounds and well situated for Truro. It is well decorated and there is comfortable furniture and fittings provided. The home was clean and tidy throughout at the time of the unannounced inspection. There are written guidelines in place to ensure good hygiene is maintained and suitable arrangements in place for soiled laundry to protect staff and residents from cross-infection. Suitable facilities are in place to ensure good hand hygiene, though the registered provider agreed to install new hand washing facilities in the bathroom and adjacent toilets on the first floor. Shower trays and baths were clean. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 18 The laundry is small, domestic in nature, but functional. Sheets are laundered by an external contractor. The front lounge is designated as ‘private’ for the use of the registered provider and family only. However, some of the residents access their rooms through this lounge and both the registered providers smoke. Cigarette smoke was noticeable in this room and also in the adjacent corridor leading to residents’ rooms. The registered providers’ attention was drawn to recent changes in smoking legislation and advised to review the arrangement to ensure compliance. Sansigra DS0000009166.V360694.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, 33, 34, 35 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff have the training to meet the needs of residents. Residents are supported by the home’s recruitment procedure. There are insufficient numbers of staff. EVIDENCE: There is a ‘at a glance’ record of all staff training, supported by individual certificates of achievement and attendance relating to the one staff member. There is no duty rota. There is no evidence of the hours worked by the registered providers. The registered providers said that both daughters also work at the home, though they both also have other jobs. There is no evidence of the hours worked by the daughters. There is documentary evidence for only one member of staff. All the care documentation inspected indicates that the residents need one carer to input with personal care, but it is not possible to see how this is achieved without properly identified staff hours. The registered providers need time off so that they can commit to the welfare of the residents when they are on duty. Similarly it is difficult to understand how transport arrangements and appointments do not impact on other residents without sufficient staff on duty to negate the need for all residents to go out when Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 20 perhaps only one needs or wants to. There is no evidence of the staff to resident ratio being determined according to the assessed needs of the residents, or that the levels reflect the changing needs of the residents. There are properly acquired references and Criminal Records Bureau checks in place for the registered providers and one staff member. There are General Social Care Council handbooks available and the registered provider showed the inspectors the National Training Organisation induction that was started by a member of staff that has since left. Sansigra DS0000009166.V360694.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, 38, 39, 42 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is insufficient evidence to support the assertion that residents benefit from a well run home. The home has gone some way to ascertaining the views of others about the home. The health and safety of residents is protected. EVIDENCE: The registered providers are in day-to-day control of the home. There is no registered manager. The registered providers are experienced and Mrs Penellum is appropriately trained having achieved the Registered Managers Award. However, doubts about the residents rights to self-determination, choice and their ability to take responsible risks are a common theme in this report and for that reason, along with the lack of clear staffing arrangements, the inspectors cannot say that the home is run for their benefit with any degree of certainty. Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 22 There is no annual development plan for the home. The registered provider showed the inspectors returns from last years’ annual quality assurance questionnaire, which they send to family and relevant professionals. As discussed this could be improved with a variety of questions being asked and more opportunity for open questions as opposed to the currently predominant multiple-choice style. Also discussed with the registered provider was what happens to the information gleaned from the returns. There are appropriate fire safety system maintenance contracts in place. There is evidence of regular maintenance and checking of other systems (gas safety certificate, electrical wiring). Sansigra DS0000009166.V360694.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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 1 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 2 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 1 1 2 X X 3 X Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 24 NO 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 YA1 Regulation 5 Requirement Timescale for action 01/05/08 2. YA6 YA7 YA9 YA18 The registered provider must ensure that residents or their representatives have the information they need. Specifically in this instance the amount and method of payment of charges. 12, 15, 16 The registered provider must review and amend the individual assessments, care plans, and related records. The registered provider must demonstrate the promotion of the residents’ right to make choices and to take responsible risks. The registered provider must make arrangements for monies due to individual residents to be paid direct into the individuals’ bank account. The registered provider must make arrangements to ensure that they do not act as agents (appointee) for the residents. The registered provider must keep an accurate record of the 01/05/08 3. YA7 17, 20 01/04/08 Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 25 4. YA13 YA15 YA16 home’s charges to residents, including any extra amounts payable, and the amounts paid by or in respect of each resident. 12, 16, 17 The registered provider must 01/06/08 take into account the individual wishes of the residents and make arrangements for access to a variety of activities that reflect these. The registered provider must make arrangements to enable the residents to engage in local, social and community activities and to establish and maintain contact with family and friends whilst living at Sansigra. The registered provider must keep a record of all visitors to the home, including the names of visitors. The registered provider must provide a planned menu, taking into account the views of the residents, and a record of the actual food provided. The registered provider must arrange for a professional opinion of the current diet offered in order to ensure that a nutritious, balanced diet is provided. The registered provider must provide the means for residents to prepare their own food, where appropriate. The registered provider must provide a duty roster and a record of whether the roster was actually worked. The registered provider must ensure there are sufficient, suitably qualified, competent 5. YA17 16, 17 01/04/08 6. YA33 17, 18 01/04/08 Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 26 staff on duty at all times. 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 YA20 Good Practice Recommendations The registered provider should obtain permission and a definitive list from the relevant GP(s) regarding the administration of non-prescribed homely remedies such as paracetamol, linctus, etc. The registered provider must ensure that the initial/signature used on Medicine Administration Records is such that it is possible to identify the person responsible for administering the medicine. The registered provider should consider providing the complaints procedure to residents in an alternative format suitable to their individual needs. The registered provider should review the current quality assurance questionnaire and publish a summary of the information provided. 2. 3. YA22 YA39 Sansigra DS0000009166.V360694.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sansigra DS0000009166.V360694.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!